The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP)
Surgical operations, in contrast to medical treatments of chronic diseases, lend themselves to observation by outcome studies. Whether patients live or die, have complications, are cured, have their symptoms relieved, return to work or play, and are satisfied with their care are very important issues vital to the assessment of the quality of surgical care. The Veterans Administration Health System (VA) addressed surgical quality improvement by developing the National Surgical Quality Improvement Program (NSQIP) to employ a prospective, peer-controlled, validated database to quantify 30-day risk-adjusted surgical outcomes.
Dedicated, trained, NSQIP nurses collect specific preoperative, intraoperative, and post-operative data. Statistical analysis of the preoperative data identifies risk factors predictive of outcome. Further analysis calculates the expected outcome of a patient population. The observed outcome/expected outcome (O/E ratio) denotes the risk-adjusted outcome. A low O/E ratio indicates better than expected outcome and a high O/E ratio indicates poorer than expected outcome (mortality, morbidity, or other). The NSQIP O/E ratio, based on valid, reliable data measures the quality of surgical care. This risk-adjustment allows valid comparisons of outcomes among all hospitals in the program. Also, the NSQIP data identifies sources of morbidity and mortality to enable management practices and improvement of the processes of care to reduce morbidity and mortality. After implementation of the NSQIP, between 1992 and 2002, the VA surgical mortality decreased 27% and the morbidity decreased 45%.
After recognizing the effectiveness of the NSQIP the leaders in the VA arranged for its preliminary evaluation in 3 university hospitals, Emory University, University of Kentucky, and the University of Michigan. The program worked very well in that setting. Then the VA and the American College of Surgeons (ACS) began collaboration for further application of the NSQIP in the private sector. With support from a grant from the Agency for Healthcare Research and Quality (AHRQ) to the ACS the NSQIP was introduced into 11 additional university hospitals. Later data was included from 4 affiliated community hospitals. With 2 years of complete data the NSQIP functions very well in these 18 private sector hospitals.
The private sector hospitals could not use VA resources, facilities, or information systems. For that reason, a private company QCMetrix, developed a web-based data collection system and trained the private sector nurses. The Colorado Health Outcomes Program (COHO) affiliated with the University of Colorado provides biostatistical services, data management, and report preparation for the private sector initiative.
In addition to proven performance in the VA, 4 year’s private sector experience has demonstrated the effectiveness of the NSQIP as a quality improvement tool and a source of new clinical knowledge. So the ACS developed a business plan to offer this program, beginning with General and Vascular Surgery, to all interested hospitals. The VA program will continue as the VA NSQIP and the private sector initiative will become the ACS NSQIP.
The ACS NSQIP will contribute to the reduction of surgical mortality and morbidity. The success of ACS NSQIP depends upon several factors. First, the trained, dedicated nurses provide reliable data. The program includes measures of reliability of the data collection so there is minimal variability among the hospitals in the program. Second, each hospital must have a surgeon responsible for the conduct of the program. The surgeon works closely with the nurse and monitors the data. Third, an Executive Committee reviews the reports provided to the hospitals on a regular basis. Fourth, the ACS NSQIP generates Best Practices from the database and makes them available on the website. Fifth, the surgeon and the nurse can review their hospital’s data (unadjusted) on the website and compare it with the means of the other hospitals in the program contemporaneously. The website provides a very versatile instrument for drilling down into the database to examine the variables in detail. This database can form the cornerstone of the morbidity and mortality conference and other quality improvement programs in the hospital. All ACS NSQIP data is encrypted when it leaves the participating hospital for management by QCMetrix and COHO. Also, all hospitals are de-identified in the database. All data is confidential. In the semi annual risk-adjusted reports the hospitals can only identify themselves. Confidentiality is maintained for surgeons, hospitals and patients.
The ACS and the APSF recently collaborated to submit a proposal to the National Library of Medicine requesting funds to investigate the feasibility of transferring intraoperative data to the ACS NSQIP database from the Anesthesia Information Management System operating in some hospitals. The availability of intraoperative hemodynamic, metabolic, and temperature data could substantially improve the capacity of the ACS NSQIP to predict and evaluate surgical outcomes. The ACS NSQIP provides an excellent opportunity for surgeons, anesthesiologists, and nurse anesthetists to work together effectively to evaluate and thereby improve surgical outcomes.
The reduction of morbidity and mortality are sufficient justification to employ this program. It has the added advantage of allowing surgeons to fulfill their professional responsibility of self-evaluation. It is also an excellent opportunity for surgeons to work in collaboration with the leaders of hospital administration, anesthesiology, and nursing services to benefit patients.
As representatives of the American College of Surgeons we sincerely hope the administrators, surgeons, anesthesiologists, nurse anesthetists, and nurses of all hospitals choose to introduce, maintain, and use this unique surgical quality improvement tool.
Dr. Jones is Director, Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, and Professor of Surgery University of Virginia, Charlottesville, VA.