Linda Dempster, RN MA Quality and Patient Safety Vancouver Coastal Health Authority

1. Using Health Economic Framework to Determine the Benefits of Participating in a Surgical Outcomes Measurement Program Linda Dempster, RN MA Quality and Patient Safety Vancouver Coastal Health Authority

2. disclosures • Nothing to disclose

3. Objectives • Vancouver Coastal Health and B.C. Healthcare • National Surgical Quality Improvement Program (NSQIP) • Health Economic Framework • Applying the Framework • Evaluating the Program • Conclusion

4. How does the BC healthcare system operate?

5. BC Health Authorities

6. Vancouver Coastal Health Population Health and Wellness Primary Health Care Home and Community Services Mental Health and Addictions Acute Care

7. VCH serves 25% of BC’s population (over 1 million people) in 17Municipalities and 15 First Nations Communities. Vancouver Coastal Health

8. Who is Vancouver Coastal Health? 22,000 staff, 2,500 physicians and 5,000 volunteers working at 556 locations including 13 hospitals, and 15 community health centres.

9. Every day in VCH region we see: 914patients in our emergency departments 5life or threatened organ cases 316surgery patients in our operating rooms (5 days a week) 2,065ambulatory patients 1,961inpatient days 175people in the community for occupational or physical therapy (PT/OT) 891home care nursing visits 6,240residential care clients 891assisted living tenants 5,121 home support hours http://www.vch.ca/about_us/quick_facts/

10. Economic Burden of Adverse Events* The rate of AE 7.5 % The total number of discharges per year 84,043 (VCHA) Additional attributable acute care days per AE 6 days** Median cost per acute care day $ 1,100 Of which 37 % are preventable Economic burden of preventable AE $ 15,329,475 Economic burden of AE $ 41,601,285 7.5% AE x 84.043 discharges x 37%= 2,332 preventable AE per year Resources: * Baker, N. et al.: The Canadian Adverse Events Study. CMAJ. 2004. Vol. 170(11): 1678-86. **Etchells, E. et al.: The Economics of Patient Safety in Acute Care. Canadian Patient Safety Institute. 2012.

11. Reducing surgical events • We had limited data on our surgical events so invested in participating in the ACS- NSQIP program • A significant investment • No risk-adjusted data for 2 years

12. National Surgical Quality Improvement Program (ACS NSQIP) • International measurement program that allows >400 hospitals to accurately compare complication rates • American College of Surgeons • preoperative, perioperative and 30 day postoperative variables • 24 sites in BC • PHC/VCH started in 2011 with 6 sites • Identifies areas to focus on

13. VCH NSQIP by Numbers

14. Health Economic Evaluation • Competition between resource scarcity and providing the best possible care • Economic outcome measurement, efficient use of resources • Patient focused • Long-term evaluation Health Economic Evaluation System Access • Evaluation of costs and consequences in monetary units • Opportunity Costs • Cost Avoidance • Is an intervention worthwhile? Cost-Benefit Analysis • Translate results into improved access to the system, e.g. • Bed days / Patient days • Wait times • Patient Volume • Assess the potential of a quality improvement initiative before implementation Projection Analysis Acknowledgement; Stefanie Raschka health economist

15. Evaluation FrameworkStefanie Raschka, Health Economist • Quality Outcomes • Patient/Employee Satisfaction and Experiences • Adverse Events / Occurrences • Healthcare Acquired Infections • Mortality & Morbidity • 2. Productivity & Efficiency • Length of Stay • Admissions / Readmissions • Work Flow / Surgical Volume • Employee Turnover and Staff Absence Making “Cents“ • 4. Program Costs / Investments • Operational costs • Implementation costs • Training and Education • Consultancy Support • 3. Health Economics • Cost-Benefit Analysis • Return-on-Investment • Cost Avoidance • Access (e.g. additional patient days, beds freed)

16. Patient Experience Patient Experience • 30 Day Follow-up: • Use of overall satisfaction question: • “How would you rate your overall surgical experience on a scale of 1 (being the worst) and 5 (being the best) at…” • Including Open Comments

17. Physician & Staff Feedback “The way the data is collected forces surgeons to believe it. We can’t debate on standardized, risk-adjusted outcomes. We can’t hide or run away anymore!” “We are all speaking the same language”

18. Strong belief that NSQIP will improve the quality of surgical care “It provides us with powerful data we never had before” “It is bringing the idea of quality improvement to the front-line, right into the OR”

19. Using your own data to make the case Potential by Occurrence • If we reduce adverse events rate by 100%: • VCH: highest potential for SSI (2,693 pd), • Pneumonia (2,079 pd), Ventilator>48hrs (1,577 pd)

20. More Predictions • If we reduce adverse events rate by 100%: • VCH: highest potential for General Surgery (522 cases), • Orthopedics (254 cases) Patient Case Opportunities

21. Economic Burden of our Surgical Adverse Events 1,415 adverse events out of 21,680 annual inpatient cases (7%) Acknowledgement: AnalysisWorks, Vancouver B.C.

22. Enhanced Recovery After Surgery Projection Analysis - Using ERAS to Reduce Length of Stay *The analysis is based on a one year period (2011/12). The occurrence rate for complication is based on NSQIP data reports.

23. Cost Benefit Analysis with Targets

24. So- what have we done! We continue to receive ongoing funding…

25. VCH Quality Initiatives

26. SSI Prevention

27. General Surgery Pneumonia Decrease of GS Pneumonia non risk rates from 3.5% to 2.3% Avoided 32 cases of pneumonia at $10,000/case = $320,000 in cost avoidance which actually allows  access to others ICOUGH Pneumonia Prevention

28. Pneumonia Prevention Project 0 pneumonias in last 420 charts reviewed!

29. Cardiac SurgeryQI Committee: Started May 2012 Team: Nurse champions, Infection Control Practitioner, Nurse Practitioner, Anesthetists, Surgeons, Pharmacy, Nursing leaders, Quality Coordinators and Educators from Operating Room (OR), Preoperative Unit and Surgical Units. Current Projects Pneumonias SSI Intubation times Urinary tract infections

30. Major Values of NSQIPWorth the ongoing investment!! • Benchmarking • Regional collaboration and conversation: • Awareness and self-education about best practices • Trends over time • Includes the patient perspective • Standardized risk-adjusted data collection • The program bundles resources • Integration of pre- and post op outcomes

31. Conclusion • Using a health economic evaluation framework can assist in proving the worth and value of a program • It can help to predict value over time to support the initial investment

32. Thank you!