The Maine Colon Resection Database Project Quality through measurement

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The Maine Colon Resection Database
ProjectQuality through measurement?

• American College of Surgeons
• Maine Chapter
• June 6, 2008

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Lord Kelvin (William Thomson)

• "If you can not measure it, you can not improve
  it.
• "To measure is to know."

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Lord Kelvin

• "X-rays will prove to be a hoax."

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What you can measure you can improve

• How do you know you are improving if you dont
  measure it?
• Who is doing the measuring?
• Us vs them
• Who knows the results?

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Measure Database Quality?

• Update on The Maine colon resection database
• Other quality measures at MMC
• ACS Web based data capture site

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What Im not going to talk about

• The definition of Quality in Medicine
• Outcomes (much)

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Why a colon resection database?

• Colon resection is a relatively high volume
  procedure
• Complications increase hospital stay, morbidity,
  mortality, costs, misery
• There are well defined processes for improving
  care
• Standardization and measurement

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Systematic Review The Evidence That Publishing
Patient Care Performance Data Improves Quality of
Care Constance H. Fung, MD, MSHS, Et.
al. Annals of Internal Medicine 15 January 2008
Volume 148 Issue 2 Pages 111-123
Conclusion Evidence is scant, particularly about
individual providers and practices. Rigorous
evaluation of many major public reporting systems
is lacking. Evidence suggests that publicly
releasing performance data stimulates quality
improvement activity at the hospital level. The
effect of public reporting on effectiveness,
safety, and patient-centeredness remains
uncertain.
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Outcomes vs Process

• Outcomes what everyone wants to know
• Infection rate, leaks, DVTs
• Risk stratification
• Processes
• Antibiotic timing
• Choice of antibiotics
• Stopped within 24 hours?
• Hypothermia

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Examples near home

• Vascular Study Group of Northern New England
• Northern New England Cardiovascular Disease Study
  Group

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Participating sites

• Eastern Maine Medical Center
• Franklin Memorial Hospital
• Maine Medical Center
• Penobscot Bay Medical Center
• York Hospital

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Data collection

• Some Surgeon entered
• Some hospital personnel entered
• Mix of process measures and outcome measures
• Not risk stratified

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Maine Colon Project Best Practices
Database Tentative Administrative Structure
York reports
PenBay reports
EMMC reports
York Hospital
PenBay
EMMC

• Local Database administration
• Data definitions
• Inclusion criteria
• Benchmarking
• Maintenance
• Reporting

Maine College of Surgeons
ACS Maine Colon Project Web-based data
repository
ACS
MMC
Franklin
Other
Statewide Peer Reporting
MMC reports
Franklin reports
Hospital 6 reports
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• Inclusion Criteria
• Elective cases, no emergencies
• Procedure within 3 days of admission
• Adult patients
• No concomitant procedures
• Including following CPT4 procedures

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Data Dictionary
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Definitions
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Results
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Maine Colon Project Database Report for Maine
Medical Center
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Maine Colon Project Database Report for Maine
Medical Center
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Maine Colon Project Database Report for Maine
Medical Center
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Has it made us better?

• Documentation
• Antibiotic choice, timing, administration,
  discontinuation
• Hair removal (razor removal!!)
• Hypothermia
• Wound closure

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Antibiotics

• Antibiotic availability
• Administration mechanism
• By anesthesia at time of skin prep
• Epidural/cystoscopy and stent placement
• Breathing treatments, Pacers
• Documentation
• Choice
• Standardized order form and protocol
• Discontinuation
• Surgeon education

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Antibiotics

• Realtime concurrent analysis
• Identification of cases
• Tracking of antibiotic choice and timeliness
• If wrong, feedback to surgeon that day

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Data collection efforts within MMC

• Infection control data collection
• Center for Performance Improvement
• MMC database
• NNE vascular and cardiovascular databases
• SCIP
• consortium
• NSQIP
• consortium

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Hospital data collection

• FTE(s) many
• Other costs ?
• Department CPI, Epidemiology and infection
  prevention
• Sampling
• Percent of colon resections sampled 100(?)
• Other cases yes, all
• Data kept in various places
• Date started long time ago
• Definitions codes, procedures, surgeons
• Reporting
• To the doctor sporadic
• Department routine to departments

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MMC database

• FTE(s) .2 - .4 ?
• Other costs not much
• Department Surgery
• Sampling
• Percent of colon resections sampled 100
• Other cases NO
• Data kept in Web based database
• Date started January 2006
• Definitions CDC/SCIP
• Reporting Quarterly and PRN

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NSQIP

• ACS
• Risk adjusted
• Outcomes
• 30 day morbidity and mortality
• Major surgical procedures

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NSQIP

• FTE(s) 1 surgical clinical nurse reviewer
• Other costs 35,000 yearly software
• Department Surgery
• Sampling
• Percent of colon resections sampled ?
• Other cases yes
• Data kept in ACS NSQIP web site
• Date started at MMC 2008
• Definitions NSQIP Et. al.
• Reporting semiannual (MMC first one June 08)

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NSQIP data collected

• Demographics 6 variables
• Surgical Profile 11 variables
• Pre-operative Data 44 clinical variables 13
  laboratory variables
• Intra-operative Data 16 clinical variables 3
  occurrence variables
• Post-operative Data 20 occurrence variables, 12
  laboratory variables 10 discharge variables

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SCIP

• Surgical Care Improvement Project
• CMS
• CDC
• National Expert Panel

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SCIP national expert panel

• American College of SurgeonsAmerican Hospital
  Assn.APICIDSAJCAHOSociety for Healthcare
  Epidemiology of AmericaAssociation of
  PeriOperativeRegistered NursesSurgical Infection
  SocietyVHA, Inc.American Academy of Orthopedic
  SurgeonsAmerican Society of AnesthesiologistsAme
  rican Society of Health System PharmacistsAmerica
  n Geriatrics SocietySociety of Thoracic
  SurgeonsPremiere

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SCIP - procedures

• Cardiac
• Coronary Artery Bypass Graft (CABG)
• Colon
• Hip Knee Arthroplasty
• Abdominal Vaginal Hysterectomy
• Vascular Surgery
• Aneurysm repair
• Thromboendarterectomy
• Vein Bypass

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SCIP - modules

• Surgical infection prevention shaving, glucose,
  temperature
• Cardiovascular complication prevention
• Venous thromboembolism prevention
• Respiratory complication prevention

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• Infection
• SCIP INF 1 Prophylactic antibiotic received
  within one hour prior to surgical incision
• SCIP INF 2 Prophylactic antibiotic selection for
  surgical patients
• SCIP INF 3 Prophylactic antibiotics discontinued
  within 24 hours after surgery end time (48 hours
  for cardiac patients)
• SCIP INF 4 Cardiac surgery patients with
  controlled 6 a.m. postoperative serum glucose
• SCIP INF 5 Postoperative wound infection
  diagnosed during index hospitalization
• (OUTCOME)
• SCIP INF 6 Surgery patients with appropriate
  hair removal
• SCIP INF 7 Colorectal surgery patients with
  immediate postoperative normothermia

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SCIP - goal

• GoalTo reduce preventable surgical morbidity and
  mortality by 25 by 2010

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SCIP

• FTE(s) 1
• Other costs no play, no pay!
• Department CPI / Surgery
• Sampling
• Percent of colon resections sampled few
• Other cases yes
• Data kept in web site
• Date started (at MMC) Early 2008
• Definitions SCIP/CDC
• Reporting to occur

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Data collection outside of MMC

• Leapfrog
• MMC PHO
• Maine health
• Maine healthcare purchasing coalition
• Blue ribbon web site
• CMS
• AHRQ
• Healthgrades
• Hospital compare

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Status of ACS web site

• For colon resection data

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• ACS database
• Obtain signed BAAs.
• Establish administration and management of
  database.
• Final check for errors/ need for changes in data
  entry process.
• Finalize report formats, individual site
  statewide.
• Establish means of data entry at each site.
• Begin active data entry (set start-up date).
• Back-load cases from 2007-present.
• Develop and begin reporting cycle.
• Clearly demonstrate Best Practices in Colon
  Surgery in Maine.

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Questions/comments?