The Department of Veterans Affairs’

• An annual report prepared for the chief of surgery of each medical center, comparing local outcomes with those of other (anonymous) VA hospitals and to the performance of all VA hospitals combined. • An annual performance evaluation by an executive committee that communicates praise or concerns about high- and low-performing centers. • The provision of self-assessment tools for use by local centers to improve care. • Structured site visits by a team of experts, when requested by local centers, to evaluate potential problems and give advice regarding care and performance.

• Identification and dissemination of good practices associated with better outcomes. 2. How were benchmark standards established? In 1993, the Veterans Health Administration (VHA) conducted the National VA Surgical Risk Study (NVASRS), with the aim of developing and validating risk-adjustment models for the prediction of surgical outcome and the comparative assessment of the quality of surgical care among multiple facilities. On the basis of data from 87,078 major surgical procedures, risk-adjustment models for 30-day mortality and morbidity rates were developed for all non-cardiac surgery and for various sub-specialties.

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The ability of these models to detect variations in the quality of surgical care was demonstrated in a validation study. Separate models were developed for risk adjustment of the 30-day mortality rate of cardiac surgery, based on a previously published methodology. The NVASRS provided the VHA with a validated tool with which the quality of surgery could potentially be monitored, compared, and improved in all 132 of the VAMCs performing surgery.

Hence, based on the results of the NVASRS, the National VA Surgical Quality Improvement Program (NSQIP) was established in January 1994; it provided, for the first time, a reporting and managerial structure for the continuous monitoring and enhancement of the quality of surgical care in the VHA. 3. How were computer-based records leveraged for their measurements? The VHA has a uniform clinical and administrative data base and software program, the decentralized hospital computer program currently known as VISTA.

This has permitted the NSQIP to gain access to a consistent surgical scheduling module and operating room log in every VAMC to identify all procedures performed throughout the country and to create and use a dedicated risk-assessment and outcome module into which all the surgical nurse reviewers enter the same data everywhere. Risk adjustment data are entered by the SCNR into a special risk-assessment software module, which is integrated into the surgery module.

Uniform software updates and changes to the definitions and help screens in the software ensure uniform data collection. After completion of data collection that also abstracts information from other parts of VISTA (e. g. , the laboratory and administrative components) automatically, the appropriate data fields are automatically electronically transferred to the data coordinating center for further cleaning and analysis. Logistic regression analysis is used to develop the predictive models for surgical death and complications.

The logistic procedure in SAS version 6. 1210 is used to perform the calculations. For each VAMC, O/E ratios (observed number of deaths or patients with complications divided by the expected number of deaths or patients with complications) are calculated for all surgical procedures combined and for each of nine major sub-specialties. Ninety percent confidence intervals (CIs) are calculated for death O/E ratios and 99% CIs for complications O/E ratios based on the binomial distribution. 4. What improvements were implemented?

• Since the inception of the NVASRS and the NSQIP, the volume of major surgery performed in the VHA has remained approximately the same, whereas the average complexity of major surgery has declined. The average risk factor profiles of the veterans undergoing major surgery have remained remarkably similar. Since 1991, the 30-day mortality rate after major surgery has decreased from 3. 1% to 2. 8%, a 9. 6% decline. • Since 1991, anesthetic and surgical techniques have improved, resulting in lower surgical risk for many patients.

Concurrent with these changes, the VHA has implemented a rigorous program of surgical attending oversight of the process of care by resident operators, particularly in surgical suites. • Hospitals with consistently low outlier status are commended and encouraged to share with the NSQIP (which subsequently disseminates this information to the rest of the medical centers) the processes and structures that these hospitals consider to have contributed to their good performance.

• Various levels of concern are raised about high outlier hospitals, and suggestions are forwarded regarding internal and external reviews to verify and improve outcomes of surgery at these hospitals. • The NSQIP has developed a set of guidelines to help the providers in the field conduct structured internal reviews to identify problems in the quality of their surgical care. • Through an ongoing dialogue with the chief medical officers of the 22 VISNs, the NSQIP provides management with advice regarding reviews of problematic surgical services and expertise in conducting external reviews and site visits.

5. How were ongoing practices controlled? Feedback is provided primarily through an annual evaluation by peers of the results at each medical center, and by the generation of an annual report distributed to the chief of surgery, the SCNR, the director, and the chief of staff of each VAMC, and the chief medical officer of each VISN. The annual report for each facility is designed to allow the providers to compare their volume, patient risk profiles, and risk-adjusted outcomes to the national average and to the averages in their peer group of hospitals.

Each hospital is identified by a specific code known only to the providers and managers at that hospital and the chief medical officer of the VISN. At the end of each fiscal year, the coordinating centers at Hines and Denver prepare tables of the observed and expected outcomes and the O/E ratios at each medical center. These tables are then reviewed by a panel consisting of members of the NSQIP executive committee and three or four additional chiefs of surgery from VAMCs. Panel members are blinded to the identity of the medical centers during the review.

Recommendations regarding specific hospitals (in all surgery and the subspecialties) are made in accordance with preset guidelines and forwarded to the above persons along with the annual report. Hospitals with consistently low outlier status are commended and encouraged to share with the NSQIP (which subsequently disseminates this information to the rest of the medical centers) the processes and structures that these hospitals consider to have contributed to their good performance.

Various levels of concern are raised about high outlier hospitals, and suggestions are forwarded regarding internal and external reviews to verify and improve outcomes of surgery at these hospitals. The NSQIP has developed a set of guidelines to help the providers in the field conduct structured internal reviews to identify problems in the quality of their surgical care. Through an ongoing dialogue with the chief medical officers of the 22 VISNs, the NSQIP provides management with advice regarding reviews of problematic surgical services and expertise in conducting external reviews and site visits.

Additional feedback for cardiac surgery is provided by a semiannual report that includes more information; it is generated by the coordinating center in Denver. The cardiac surgery consultants committee also reviews the various hospitals’ reports before they are distributed and makes specific recommendations regarding high and low outliers to the Office of Patient Care Services at Headquarters and to the chief medical officers in the VISNs. References:

• Healthcare Information Management Systems: Cases, Strategies and Solutions 3rd Edition – Marion J.Ball, Charlotte A. Weaver and Joan M. Kiel • http://www. ncbi. nlm. nih. gov/pubmed/9790339 The Department of Veterans Affairs’ NSQIP: the first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care. National VA Surgical Quality Improvement Program. Khuri SF, Daley J, Henderson W, Hur K, Demakis J, Aust JB, Chong V, Fabri PJ, Gibbs JO, Grover F, Hammermeister K, Irvin G 3rd, McDonald G, Passaro E Jr, Phillips L, Scamman F, Spencer J, Stremple JF.

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