The power of the National Surgical Quality Improvement Program--achieving a zero pneumonia rate in general surgery patients

Abstract

The National Surgical Quality Improvement Program (NSQIP) of the American College of Surgeons provides risk-adjusted surgical outcome measures for participating hospitals that can be used for performance improvement of surgical mortality and morbidity. A surgical clinical nurse reviewer collects 135 clinical variables including preoperative risk factors, intraoperative variables, and 30-day postoperative mortality and morbidity outcomes for patients undergoing major surgical procedures. A report on mortality and complications is prepared twice a year. This article summarizes briefly the history of NSQIP and how its report on surgical outcomes can be used for performance improvement within a hospital system. In particular, it describes how to drive performance improvement with NSQIP data using the example of postoperative respiratory complications--a major factor of postoperative mortality. In addition, this article explains the benefit of a collaborative of several participating NSQIP hospitals and describes how to develop a "playbook" on the basis of an outcome improvement project.

Figure 1

Timeline of the events that led to the creation of the American College of Surgeons National Surgical Quality Improvement Program, 1985 to 2004. ACS = American College of Surgeons; NSQIP = National Surgical Quality Improvement Program; VA = Veterans Administration

Figure 2

Initial rank of two hospitals in the category of mortality is reversed after risk adjustment because of the difference of expected mortalities of their patient populations. This demonstrates the importance of risk adjustment.

Figure 3

Overall nonmultispecialty 30-day mortality of observed vs expected ratios for participating NSQIP hospitals. Each vertical line represents the confidence interval (CI) of one hospital. The CI lines of hospitals with significantly better outcomes are entirely below the mean (solid horizontal line); the CI lines of hospitals with significantly better outcomes are entirely above the mean. Confidence interval = 90%; NSQIP = National Surgical Quality Improvement Program; O/E = observed vs expected

Figure 4

Observed vs expected (O/E) ratios for general surgery outcomes for a specific hospital, January 2011. The mean and confidence interval for an individual hospital are shown within a bar. The bar depicts the outcome of all hospitals with the subdivision representing the ten deciles. The O/E ratio for the particular hospital is shown at the top of the chart. DVT/PE = deep venous thrombosis/pulmonary embolism; O/E = observed vs expected; SSI = surgical site infection; UTI = urinary tract infection

Figure 5

Risk-adjusted semiannual NSQIP report for all complication at all hospitals. The rank of a particular hospital is indicated by the large arrow within the group of all participating hospitals. DVT/PE = deep venous thrombosis/pulmonary embolism; NSQIP = National Surgical Quality Improvement Program; UTI = urinary tract infection

Figure 6

Risk-adjusted results of >48-hours intubation for the Walnut Creek Medical Center in 2008 and 2009, comparing results before and after implementation of the performance-improvement project.

Figure 7

NSQIP raw data and run chart: >48-hours intubation performance-improvement project. The initiation of the performance-improvement project led to a reduction of the incidence and mortality of this complication. Benchmark refers to the mean performance of the whole NSQIP cohort. First half of 2007 (approximately 700 patients), n = 22; 10 patients died. First half of 2008 (approximately 800 patients), n = 20; 6 patients died. First half of 2009 (approximately 800 patients), n = 15, 4 patients died. Second half of 2009 (approximately 800 patients), n = 10; 3 patients died. NSQIP = National Surgical Quality Improvement Program

Figure 8

Risk-adjusted NSQIP results for postoperative pneumonias in general surgery patients for 2009. After implementation of the postoperative pneumonia bundle, our hospital achieved significantly better outcomes than the NSQIP cohort (see inset) on the basis of risk-adjusted outcome improvement. The inset shows the performance of our hospital for this complication from early 2007 to late 2009. NSQIP = National Surgical Quality Improvement Program

Figure 9

Run chart of postoperative-pneumonia incidence in general surgery patients.

Figure 10

Plan-Do-Study-Act protocol for the development of the wound classification playbook for the Kaiser Permanente Northern California NSQIP collaborative. CDC = Centers for Disease Control and Prevention; NSQIP = National Surgical Quality Improvement Program; OR = operating room; SCNR = surgical clinical nurse reviewers

Figure 11

Steps and timeline to achieve a 90% target for accuracy in wound classification using a performance-improvement project developed by the NSQIP team at the Kaiser Permanente Modesto Medical Center. NSQIP = National Surgical Quality Improvement Program