The Veterans Health Administration (VHA) adopted the National Surgical Quality Improvement Program (NSQIP). This program is a physician-driven comparison study initiated by senior surgeons between 1991 and 1997, in which mortality and morbidity rates were “risk adjusted and compared to observed-to-expected ratios” (Ball, Weaver, & Kiel, 2004, p. 277). They studied data in order to determine the efficacy of surgical procedures from the pre-operative- through 30-day post-operative periods. 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 (NVASRS).
The VHA’s NSQIP includes chief of surgery in VHA from each medical center, prepared annual report comparing local outcomes with those of other VA hospitals performance of all VA hospitals combined. The information technology (IT) system, VISTA, is an electronic medical record system developed by the VHA, which uniformly connects the entire VAMC system and was utilized in the compilation of the necessary data (Ball, Weaver, & Kiel, 2004). 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). 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. 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). Risk-adjustment models for 30-day mortality and morbidity rates were developed for all non-cardiac surgery and for various sub-specialties.
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 of the VAMCs performing surgery (Best, Khuri, & Phelan, 2002). Therefore, based on the results of the NVASRS, NSQIP was established in 1994. It was the first structure that provided a way to continuously monitoring and enhances the quality of surgical care in the VHA. NSQIP reports that since 1994 the 30-day mortality and morbidity rate for major surgery have fallen 9% to 30% respectively (Best, Khuri, & Phelan, 2002). Computer-Based Records Used for Measurements
The information technology (IT) system, VISTA, is an electronic medical record (EMR) system developed by the VHA to connect the entire VAMC system. It was used to compile all of the data necessary for research. This has permitted the NSQIP to gain access to a consistent surgical scheduling module and operating room log in every VAMC. This allows them 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 (Best, Khuri, & Phelan, 2002). A total of 88 permanent full-time-equivalent positions have been assigned for trained surgical clinical nurse reviewers (SCNRs) at the VAMCs participating in the program (Best, Khuri, & Phelan, 2002). The SCNRs worked closely with the chief of surgery at each VAMC to ensure the accurate collection and timely transmission of the data. Risk adjustment data are entered by the SCNR into a special risk-assessment software module, which is integrated into the surgery module.
Logistic regression analysis is used to develop the predictive models for surgical death and complications. In the logistic regression model, surgical death and complications are the dependent variables, and the pre-surgical risk factors are the independent variables. Surgical mortality is defined as the death of a patient within 30-days after the index surgical procedure, in or out of the hospital. The logistic procedure in SAS version 6.12 is used to perform the calculations. They intended to show that the quality of care provided for the patients was equal to the outcomes produced within the study and initiated solid evidenced-based practice (EBP) protocols to ensure improvement of outcomes (Best, Khuri, & Phelan, 2002). Improvements Implemented
Improvements were noted across the spectrum after the program was initiated. The 30-day mortality rate improved by 9.6%, the 30-day morbidity rate by 30% and length of stays decreased from 10.2 days to 5.1 days (50% improvement). The VAMC sites with the greatest improvements also noted a significant improvement in patient satisfaction (Best, Khuri, & Phelan, 2002). 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 (Ball, Weaver, & Kiel, 2004).
The VHA implemented a rigorous program of surgical attending oversight of the process of care by resident operators, particularly in surgical suites. 85% to 95% of all major surgery in the VHA has a surgical resident identified as the primary operator in the NSQIP database. Systematic collection and reporting of surgical deaths and complications by the NSQIP resulted in a drop in the surgical mortality rate through changes in surgical process of care (Best, Khuri, & Phelan, 2002).
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. Hospitals with consistently low outlier status are commended and encouraged to share with the NSQIP. This subsequently disseminates the information to the rest of the medical centers. The processes and structures that these hospitals adopted have contributed to their good performance (Best, Khuri, & Phelan, 2002). Controlling Outgoing Practices
The NSQIP is an ongoing quality-management initiative that applies the methods developed and validated by the NVASRS to all the VAMCs that perform major surgery. Peers using the results at each medical center provide feedback primarily through an annual evaluation. The generation of an annual report is distributed to the chief of surgery, the director, the chief of staff of each VAMC, and the chief medical officer of each Veterans Integrated Service Networks (VISN). This 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 (Ball, Weaver, & Kiel, 2004).
The NSQIP has developed a set of guidelines to help the providers conduct structured internal reviews to identify problems in the quality of their surgical care. Through an ongoing dialogue with the chief medical officers, the NSQIP provides management with advice regarding reviews of problematic surgical services and expertise in conducting external reviews and site visits. Surgical community has been fearful that the information in the NSQIP will be used against those surgical services with higher-than-expected outcomes in a punitive manner by administrative managers without sophisticated knowledge of surgical practice. The executive committee of the NSQIP has worked hard to educate all the participants in the NSQIP that the intent of the program is for overall quality improvement in surgical practice in the VHA.
Best, W., Khuri, S., & Phelan, M. (2002). 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. 194(3), 257-266. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1191523/pdf/annsurg00008-0067.pdf
Ball, M., Weaver, C., & Kiel, J. (2004). Healthcare Information Management Systems: Cases, Strategies and Solutions (3rd ed), 277-278.