During the 1980s, the Department of Veterans Affairs (VA) received significant public scrutiny over the quality of surgical care in their hospitals. This motivated Congress to mandate reporting of surgical outcomes annually and led to the important National VA Surgical Risk Study (NVASRS) across 44 VA medical centers (Fuchshuber, P. , Greif, W. , Tidman, C. , Klemm, M. , Frydel, C. , Wali, A. , Rosas, E. & Clopp, M. , 2012).
The Veterans Health Administration (VHA) adopted the National Surgical Quality Improvement Program (NSQIP) because senior surgeons realized they needed improvement as they were seeing surgery complications such as infections, blood clots or respiratory failure. It is a known fact that postoperative complications can increase death rates, longer hospital stays and increase the cost of care itself. Having the surgeons on board was a great opportunity to encourage the change in a positive mannerism when it was time to roll out the mandated changes.
They studied data in order to determine the efficacy of surgical procedures from the pre-operative- through 30-day post-operative periods (Ball, Weaver, & Kiel, 2004, p. 277). This study was intended to improve the quality of care provided to patients throughout the Veterans Administration Medical Centers (VAMC) nationwide during the operative periods stated above by utilizing the National VA Surgical Risk Study (2012). Benchmark Standards Established The NSQIP was created by the VHA to extend the methods and reporting developed in the National VA Surgical Risk Study (NVASRS).
The benchmark was established by looking at areas that needed improvement and to increase surgical outcomes (Pope & Russell). Their aim was to develop and validate risk-adjustment models to predict surgical outcome, and for comparative assessment of the quality of surgical care across multiple facilities. As a result, the VA embarked upon the National VA Surgical Risk Study (NVASRS) in 44 VA medical centers. The foundation for their work was Lisa Lezzoni’s “algebra of effectiveness,” which states that outcomes of healthcare can be described by this equation: Patient Factors + Effectiveness of Care + Random Variation = Outcome.
During this period, a dedicated nurse in each of the 44 medical centers collected preoperative, intraoperative and 30-day outcome variables on more than 117,000 major operations. Using this data, the NVASRS was able to develop risk models for 30-day mortality and morbidity in nine surgical specialties (Pope & Russell). This work allowed for the first time, a comparative measurement of the quality of surgical care in the nine specialties. For this equation to move from theory to practical application, the VA recognized it needed to build a statistically reliable database of patients’ preoperative risk factors and postoperative outcomes.
It also had to create methods for accurate risk adjustment and to account for random events. The NSQIP program was implemented to provide reliable, valid and comparative information about surgical outcomes across over a hundred VAMC’s that perform major surgery (Best, Khuri, & Phelan, 2002). How were computer-based records were leveraged (Using a tool for an advantage) for their measurements? Being able to use the VISTA system (Veterans Health Information Systems and Technology Architecture) helped using computer based records by using EMR is a great place to start and is a tool that we are so lucky to have.
Not only was the VISTA used now for quality measures, but it is used worldwide for the armed forces to keep track of veterans and other armed forces medical needs and issues that can be utilizes anywhere that the person lives or is stationed. The VISTA system was the first software that could be used for clinical measurements; the VISTA system was a proven product and can be readily adapted for use in acute care, ambulatory, and long-term care setting (Hynes, D. M. , 2004).
VISTA software is in the public domain and has been available to non-VA users under the Freedom of Information Act (FOIA) for several decades. Like open source software, the application code is made available to anyone requesting a copy of the system. Therefore, in the paradigm we have discussed in this book, VISTA falls under the broad term of Free and Open Source Software (Hynes, D. M. , 2004) When you are trying to keep track of quality numbers and the extensive PDSA’s for process improvement and quality of care is a godsend.
Being able to put in your numerator and denominator and then send it to another hospital to add their study number s etc. is very accurate and less chance of error margin. I have been involved with quality for many years and personally have seen the change upfront with being able to use data from other hospitals that are equal to our size, or even when I am doing a PDSA or looking at tools for improving patient care, being able to access and utilize other hospital policies and procedures is so much help for me as why create a wheel when it is already turning.
Plus, with not having a large committee and not one person on our committee has the pleasure of just doing quality only, it is very time consuming and many time unpractical if I did not have computer-based records at my fingertips too help me out for studies and now to send in our meaningful use numbers. What improvements were implemented? With looking at both the best of the best and the VAH that were teetering on poor quality outcomes, they were able to observe and see that the surgery areas that had better outcomes had consistent communication between all multidisciplinary team members, and with the patients.
It was also noted that protocols and best practice policies and procedures were up to date and utilizes as their education tool to be able to excel. The program has proved to be successful by the mortality and morbidity in the VA system being reduced by 27% and 45% (2012). It is interesting to look at the improvements and how they were made as it was the start of really taking the best practices and putting them together and looking at where there can be improvement and what changes need to be made.
They started working with performance improvement projects just like we do today. Using PSDA’s is the best way to improve your quality of care to meet the expectations of not just your patients but yourself and your facility. Besides looking at the mortality and overall morbidity, they looked at making changed in regards to cardiac complications, pneumonia, unplanned intubations, >48-hour intubations, deep venous thrombosis and pulmonary embolism [DVT/PE], renal failure, urinary tract infections [UTIs], and surgical site infections (2012).
I look at these again, and see how I am sure that at that time, they had improvement, but times have changed and now we are looking at these areas again with National Patient Safety Goals, Partnership for Patients, and Hospital Engagement Networks. How were ongoing practices controlled? An annual report prepared for the chief of surgery of each medical center would compare local outcomes with those of other VA hospitals and to the performance of all VA hospitals combined. An annual performance evaluation by an executive committee communicates praise or concerns about high- and low-performing centers (Hynes, 2004).
The provision of self-assessment tools for use by local centers to improve care is provided along with promised assistance if one needs so. They also had structured site visits by a team of experts, when requested by local centers, to evaluate potential problems and give advice regarding care and performance (Hynes, 2004). They would also recognized and broadcast best practices that were related to better outcomes. As looking at what we first started by this group is still what is going on at our facility and many others.
I still am a firm believer in that you need to praise, praise, praise all the good and really broadcast the best practices outside of just the health care facility and be proud of who and what you have done. References Ball, M. , Weaver, C. , Kiel, J. , 2004, Healthcare Information Management Systems: cases strategies and solutions Third Ed pp. 11. p. 277-278. Best, W. R. , & Khuri, S. F. & Phelan, M. (2002). Identifying patient preoperative adverse events in administrative databases: Results from the department of veterans affairs national surgical quality improvement program.
Journal of the American College of Surgeons. 194(3):399-. Fuchshuber, P. , Greif, W. , Tidman, C. , Klemm, M. , Frydel, C. , Wali, A. , Rosas, E. & Clopp, M. (2012). The Power of the National Surgical Quality Improvement Program—Achieving A Zero Pneumonia Rate in General Surgery Patients. The Permanente Journal. 16(1). Hynes, D. M. , (2004). Leadership by Example: Coordinating Government Roles in Improving Health Care Quality. Institute of Medicine (IOM) Report. Pgs. 223-284. Pope, G. & Russell, T. NSQIP History. American College of Surgeons. site. acsnsqip. org/program-specifics/nsqip-history/?.