Oscar Guillamondegui, MD, MPH, FACS Tennessee Surgical Quality Collaborative Associate Professor of Surgery Vanderbilt University Medical Center
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1 Oscar Guillamondegui, MD, MPH, FACS Tennessee Surgical Quality Collaborative Associate Professor of Surgery Vanderbilt University Medical Center
2 Culture Change en Masse- Efforts of a Collaborative Oscar Guillamondegui, MD, MPH, FACS Tennessee Surgical Quality Collaborative Vanderbilt University
3 Tennessee Surgical Quality Collaborative (TSQC) Background: How it All Started The Epiphany (2004) Initial Tennessee ACS NSQIP Hospitals ( ) The State-Wide ACS NSQIP Consortium Proposal (2006)
4 BC/BS and Building the Model Michigan Collaboration Example: Between BC/BS Michigan and University of Michigan BC/BS providing essentially all the funding (i.e., no cost to the participating hospital) Our Desire: Two-way collaboration between BC/BS TN and the ACS TN State Chapter Infrastructure housed at the UTCOM-Chattanooga Unit BC/BS providing most of the funding BC/BS Desire: Three-way collaboration between BC/BS TN, The Tennessee Hospital Association (THA), and the TN ACS Infrastructure housed in the Tennessee Center for Patient Safety (TCPS) BC/BS TN to provide partial funding to hospitals and funding for TCPS infrastructure
5 TSQC Goals Create a consortium of surgeons and hospitals to evaluate and improve surgical care by surgeons in the state of Tennessee Active engagement of physicians through the TnACS and collection of quality data effective in driving improvement in surgical outcomes.
6 The Original 10 Jackson Madison Medical Cookeville Regional Johnson City Medical Vanderbilt University Medical Center-Nashville Parkwest Medical Center University of TN Knoxville Medical Baptist Memorial Methodist University (UTCOM) St. Francis Hospital Erlanger (UTCOM-Chatt.) 6
7 Now 22: The New 11 + UT Memphis Vanderbilt University Medical Center-Nashville Baptist Hospital St. Thomas Hospital Summit Medical Center Claiborne County Hospital Cookeville Regional Wellmont Bristol Regional NorthCrest Medical Center Henry County Medical Center Cumberland Medical Center Johnson City Medical Jackson Madison Medical Parkwest Medical Center University of TN Knoxville Medical Ft. Sanders Medical Center Maury Regional Medical Center Erlanger (UTCOM-Chatt.) Memorial Hospital Baptist Memorial Methodist University (UTCOM) St. Francis Hospital UT Memphis 7
8 Demographics St Thomas Midtown: 683 Baptist Memorial Hospital: 732 Claiborne County Hospital: 85 Cookeville Reg Med Ctr: 247 Cumberland Med Center: 189 Erlanger: 687 Ft. Sanders Med Ctr: 517 Henry Co Medical Center: 142 Jackson Co Gen Hospital: 635 Maury Regional Medical Ctr: 255 Memorial Health: 405 Methodist Univ Hospital : 669 NorthCrest Medical Center : 109 Parkwest Med Center : 462 Regional One Health: 631 Saint Francis Hospital : 519 Saint Thomas West Hospital :541 Summit Medical Center: 188 UT Medical Ctr(Knoxville): 581 Vanderbilt University: 1,025 Wellmont Bristol Regional : 312
9 Demographics St Thomas Midtown: 683 Baptist Memorial Hospital: 732 Claiborne County Hospital: 85 Cookeville Reg Med Ctr: 247 Cumberland Med Center: 189 Erlanger: 687 Ft. Sanders Med Ctr: 517 Henry Co Medical Center: 142 Jackson Co Gen Hospital: 635 Maury Regional Medical Ctr: 255 Memorial Health: 405 Methodist Univ Hospital : 669 NorthCrest Medical Center : 109 Parkwest Med Center : 462 Regional One Health: 631 Saint Francis Hospital : 519 Saint Thomas West Hospital :541 Summit Medical Center: 188 UT Medical Ctr(Knoxville): 581 Vanderbilt University: 1,025 Wellmont Bristol Regional : 312
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11 Demographics St Thomas Midtown: 683 Baptist Memorial Hospital: 732 Claiborne County Hospital: 85 Cookeville Reg Med Ctr: 247 Cumberland Med Center: 189 Erlanger: 687 Ft. Sanders Med Ctr: 517 Henry Co Medical Center: 142 Jackson Co Gen Hospital: 635 Maury Regional Medical Ctr: 255 Memorial Health: 405 Methodist Univ Hospital : 669 NorthCrest Medical Center : 109 Parkwest Med Center : 462 Regional One Health: 631 Saint Francis Hospital : 519 Saint Thomas West Hospital :541 Summit Medical Center: 188 UT Medical Ctr(Knoxville): 581 Vanderbilt University: 1,025 Wellmont Bristol Regional : 312
12 Demographics 5 hospitals under 200 beds 7 hospitals over 600 beds 6 University Teaching Hospitals Several non-academic with resident support Greater than 67% of all operative volume
13 Getting the Surgeon Champion Involved Experiences of a Rural Surgeonand Small Hospital in joining NSQIP and TSQC Presenter: Robert Wilmoth, MD, Claiborne County Hospital Improving Documentation and consistency in assigning ASA Class Presenter: Melissa McCollough, RN and Rick Gibbs, MD, Cumberland Medical Center Using Surgical Residents to Drive Surgical Quality Improvement Efforts Presenter: Joseph Cofer, MD Erlanger Medical Center Experiences as a Beta Site for the ACS resident QITI program Presenter: Joe Cofer, MD, Erlanger Medical Center Implementing the Colon Bundle in a Small and Rural Hospital Presenter: Ray Compton, MD, Henry County Medical Center 13
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15 No Post-operative Occurrence
16 No Post-operative Occurrence 30% Improvement
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18 SSI Rates Year Total Cases Deep SSI Organ SSI Superficial SSI ALL SSI WD Total Year Total Cases Deep SSI Organ SSI Superficial SSI ALL SSI WD % 1.5% 3.4% 5.7% 0.8% % 1.7% 2.8% 5.2% 0.6% % 1.3% 2.7% 4.5% 0.4% % 1.0% 2.1% 3.7% 0.7% % 0.9% 2.1% 3.7% 0.6% Total % 1.3% 2.6% 4.5% 0.6%
19 SSI Rates Year Total Cases Deep SSI Organ SSI Superficial SSI ALL SSI WD Total Year Total Cases Deep SSI Organ SSI Superficial SSI ALL SSI WD % 1.5% 3.4% 5.7% 0.8% % 1.7% 2.8% 5.2% 0.6% % 1.3% 2.7% 4.5% 0.4% % 1.0% 2.1% 3.7% 0.7% % 0.9% 2.1% 3.7% 0.6% Total % 1.3% 2.6% 4.5% 0.6%
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23 Overall Outcomes TSQC TSQC-WIDE Per 1,000 Procedures Percentage Harms Unit Total Costs RR LCL UCL Difference Avoided Costs Per 1,000 Mortality % 257 ALLSSI % 255 ACUTE RENAL FAILURE % 81 $ 28,359 $2,286, CARDIAC ARREST REQUIRING CPR % -14 $ 15,079 ($215,645.64) DEEP INCISIONAL SSI % 30 $ 27,631 $825, DVT Requiring Therapy % -40 $ 10,804 ($427,533.40) MYOCARDIAL INFARCTION % -27 $ 14,675 ($392,697.60) ON VENTILATOR > 48 HOURS % 243 $ 27,654 $6,708, ORGAN/SPACE SSI % 14 $ 27,631 $386, PNEUMONIA % 43 $ 22,097 $941, PROGRESSIVE RENAL INSUFFICIENC % 10 $ 11,797 $117, PULMONARY EMBOLISM % 1 $ 16,644 $10, SEPSIS % 325 $ 38,978 $12,656, SEPTIC SHOCK % 65 $ 26,354 $1,704, STROKE/CVA % -25 $ 24,000 ($601,988.41) SUPERFICIAL INCISIONAL SSI % 211 $ 27,631 $5,821, UNPLANNED INTUBATION % 29 $ 21,025 $599, URINARY TRACT INFECTION % 103 $ 12,828 $1,327, WOUND DISRUPTION % 70 $ 1,426 $100, Patients w/morbidity % 530 Total Postoperative Occurrences % 1374 Total Cases Total Costs/(Avoided Costs) $31,847, Legend for color coding: Postoperative occurrences are not significantly different in 2013 compared to 2009 There are significantly less postoperative occurrences in 2013 compared to 2009 There are significantly more postoperative occurrences in 2013 compared to 2009 Harms increased
24 Overall Outcomes TSQC TSQC-WIDE Per 1,000 Procedures Percentage Harms Unit Total Costs RR LCL UCL Difference Avoided Costs Per 1,000 Mortality % 257 ALLSSI % 255 ACUTE RENAL FAILURE % 81 $ 28,359 $2,286, CARDIAC ARREST REQUIRING CPR % -14 $ 15,079 ($215,645.64) DEEP INCISIONAL SSI % 30 $ 27,631 $825, DVT Requiring Therapy % -40 $ 10,804 ($427,533.40) MYOCARDIAL INFARCTION % -27 $ 14,675 ($392,697.60) ON VENTILATOR > 48 HOURS % 243 $ 27,654 $6,708, ORGAN/SPACE SSI % 14 $ 27,631 $386, PNEUMONIA % 43 $ 22,097 $941, PROGRESSIVE RENAL INSUFFICIENC % 10 $ 11,797 $117, PULMONARY EMBOLISM $31 49 Million dollars % 1 $ 16,644 $10, SEPSIS % 325 $ 38,978 $12,656, SEPTIC SHOCK % 65 $ 26,354 $1,704, STROKE/CVA % -25 $ 24,000 ($601,988.41) SUPERFICIAL INCISIONAL SSI % 211 $ 27,631 $5,821, UNPLANNED INTUBATION % 29 $ 21,025 $599, URINARY TRACT INFECTION % 103 $ 12,828 $1,327, WOUND DISRUPTION % 70 $ 1,426 $100, Patients w/morbidity % 530 Total Postoperative Occurrences % 1374 Total Cases Total Costs/(Avoided Costs) $31,847, Legend for color coding: Postoperative occurrences are not significantly different in 2013 compared to 2009 There are significantly less postoperative occurrences in 2013 compared to 2009 There are significantly more postoperative occurrences in 2013 compared to 2009 Harms increased
25 Overall Outcomes TSQC Risk Adjusted 2012 SITE W R S T Y P L B V G F C Q O X D Z N J E H ACUTE RENAL FAILURE Higher than expected CARDIAC ARREST REQUIRING CPR As expected DEEP INCISIONAL SSI Lower than Expected DVT Requiring Therapy Mortality MYOCARDIAL INFARCTION ON VENTILATOR > 48 HOURS ORGAN/SPACE SSI PNEUMONIA PROGRESSIVE RENAL INSUFFICIENCY PULMONARY EMBOLISM SEPSIS SEPTIC SHOCK STROKE/CVA SUPERFICIAL INCISIONAL SSI UNPLANNED INTUBATION URINARY TRACT INFECTION WOUND DISRUPTION Total Postoperative Occurrences Example 1: Site E has significantly more total postoperative occurrences than expected when compared to the TSQC. Example 2: Site F has significantly fewer total postoperative occurrences than expected when compared to the TSQC.
26 Overall Outcomes TSQC 2012 Site Specific Patient Risk Compared to 2012 TSQC Patient Risk Average SITE W R S T Y P L B V G F C Q O X D Z N J E H ACUTE RENAL FAILURE Patient Risk is Higher than TSQC Average CARDIAC ARREST REQUIRING CPR Patient Risk is at the TSQC Average DEEP INCISIONAL SSI Patient Risk is Lower than TSQC Average DVT Requiring Therapy Mortality MYOCARDIAL INFARCTION ON VENTILATOR > 48 HOURS ORGAN/SPACE SSI PNEUMONIA PROGRESSIVE RENAL INSUFFICIENCY PULMONARY EMBOLISM SEPSIS SEPTIC SHOCK STROKE/CVA SUPERFICIAL INCISIONAL SSI UNPLANNED INTUBATION URINARY TRACT INFECTION WOUND DISRUPTION Total Postoperative Occurrences Example 1: Site Shas significantly lower patient risk for total postoperative occurrences than the TSQC average. Example 2: Site G has significantly greater patient risk for total postoperative occurrences than the TSQC average.
27 SITE ACUTE RENAL FAILURE CARDIAC ARREST REQUIRING CPR DEEP INCISIONAL SSI DVT Requiring Therapy Mortality MYOCARDIAL INFARCTION ON VENTILATOR > 48 HOURS ORGAN/SPACE SSI PNEUMONIA PROGRESSIVE RENAL INSUFFICIENCY PULMONARY EMBOLISM SEPSIS SEPTIC SHOCK STROKE/CVA SUPERFICIAL INCISIONAL SSI UNPLANNED INTUBATION URINARY TRACT INFECTION WOUND DISRUPTION Total Postoperative Occurrences Example 1: in 2012 Site Thad significantly more postoperative occurrences of SEPSIS than in Example 2: Site Y had significantly fewerpostoperative occurrences of Pneumonia in 2012 than in Observed Performance Compared to 2011 Observed Performance W R S T Y P L B V G Higher in 2012 than in 2011 The same in 2012 as in 2011 Lower in 2012 than in 2011
28 Example 1: Site Ghas significantly higher patient riskfor total postoperative occurrences in 2012 than in Example 2: Site Rhas significantly lower patient riskfor total postoperative occurrences in 2012 than in Site Specific Patient Risk Compared to 2011 Site Specific Patient Risk SITE ACUTE RENAL FAILURE CARDIAC ARREST REQUIRING CPR DEEP INCISIONAL SSI DVT Requiring Therapy Mortality MYOCARDIAL INFARCTION ON VENTILATOR > 48 HOURS ORGAN/SPACE SSI PNEUMONIA PROGRESSIVE RENAL INSUFFICIENCY W R S T Y P L B V G PULMONARY EMBOLISM SEPSIS SEPTIC SHOCK STROKE/CVA SUPERFICIAL INCISIONAL SSI UNPLANNED INTUBATION URINARY TRACT INFECTION WOUND DISRUPTION Total Postoperative Occurrences Patient Risk is higher in 2012 than in 2011 Patient Risk is the same in 2012 as in 2011 Patient Risk is lower in 2012 than in 2011
29 Procedure-Specific Outcomes Is there any benefit to examine the individual procedures What can be expected from the results Can best-practices be achieved even for high volume simple cases
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33 Surgeon-Specific Data Can the collaborative mimic the institutional at the surgeon-specific level? What are the hindrances? How do we achieve accurate relative risk?
34 Approach To Surgeon Specific Modeling
35 Approach To Surgeon Specific Modeling Relative Risk
36 Relative Risk Modeling
37 Approach To Surgeon Specific Modeling Exemplars 7%
38 Approach To Surgeon Specific Modeling Outliers 2%
39 Risk Models local
40 Risk Models local Worse than expected Better than expected
41 Risk Models local Worse than expected Better than expected
42 PARS and NSQIP Patient Advocacy Reporting System Wound Occurrences (in Standard Deviations) Difficult MD +1 SD Perioperative Risk -1 SD Perioperative Risk -1 SD Total Complaints +1 SD Total Complaints
43 PARS and NSQIP Patient Advocacy Reporting System Wound Occurrences (in Standard Deviations) Difficult MD +1 SD Perioperative Risk -1 SD Perioperative Risk -1 SD Total Complaints +1 SD Total Complaints
44 PARS and NSQIP Patient Advocacy Reporting System Wound Occurrences (in Standard Deviations) Difficult MD +1 SD Perioperative Risk -1 SD Perioperative Risk -1 SD Total Complaints +1 SD Total Complaints
45 PARS and NSQIP Patient Advocacy Reporting System Wound Occurrences (in Standard Deviations) Hard Case Easy Case Difficult MD +1 SD Perioperative Risk -1 SD Perioperative Risk -1 SD Total Complaints +1 SD Total Complaints
46 Promoting Professionalism Pyramid Ray, Schaffner, Federspiel, Hickson, Pichert, Webb, Gabbe, Pichert et al, Mukherjee et al, Stimson et al, Pichert et al, Hickson et al, No Pattern persists Level 3 "Disciplinary" Intervention Level 2 Guided" Intervention by Authority Apparent pattern Level 1 "Awareness" Intervention Single unprofessional" incidents (merit?) "Informal" Cup of Coffee Intervention Mandated Vast majority of professionals -no issues -provide feedback on progress Mandated Reviews Adapted from Hickson, Pichert, Webb, Gabbe. Acad Med VUMC
47 Impact Mortality reduction of 26.9%* 516 Lives saved estimate* Post-operative complications 4,427 Fewer complications* 1,660 Fewer patients with any adverse outcome* $5,441,020 Costs avoided** * Impact based on comparison of TSQC performance through 3 rd qtr2012 to baseline in 1 st qtr ** Impact based on TSQC performance for CY 2012 compared to CY
48 Lessons Learned Culture Change Collaboration and mutual respect Honest exchange on failures and areas for improvement Robust Clinical Database Surgeons trust the data Data analysis with feedback and reports to identify improvement opportunities Clarity of Focus Colon bundle 48
49 Culture Change en Masse- Efforts of a Collaborative Oscar Guillamondegui, MD, MPH, FACS Tennessee Surgical Quality Collaborative Vanderbilt University
50 Oscar Guillamondegui, MD, MPH, FACS Tennessee Surgical Quality Collaborative Associate Professor of Surgery Vanderbilt University Medical Center
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