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Progress on the Surgical Care Improvement Project (SCIP) Special Study: The Unique Role of a Surgeon Organization and Quality Surgical Solutions Hiram C. Polk, Jr. MD, FACS John N. Lewis, MD, MPH Jan P. Van Vlack, RN February 2005

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Progress on the Surgical Care Improvement Project(SCIP) Special Study:The Unique Role of aSurgeon Organization

and

Quality Surgical Solutions

Hiram C. Polk, Jr. MD, FACS

John N. Lewis, MD, MPH

Jan P. Van Vlack, RN

February 2005


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SCIP Special Study…From Surgical Infection Prevention (SIP) to SCIP

Centers for Medicare & Medicaid Services (CMS) contract awarded to:

  • Kentucky Medicare Quality Improvement Organization (QIO)

  • Ohio Medicare QIO


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SCIP Special Study continued

Subcontracts:

  • Kentucky Medicare QIO with Quality Surgical Solutions

  • Ohio Medicare QIO with Oklahoma Medicare QIO


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Quality Surgical Solutions (QSS)

A surgeon organization whose mission

is to improve quality and decrease costs of surgical care


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QSS–Added Value to SCIP

  • Surgical quality expertise

  • Surgical research and practice expertise

  • Practiced, accomplished leadership

  • Surgeon network

  • Hospital recruitment and commitment

  • Access to surgeon data on hospital case abstracted data


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Building Physician Consensus

  • Growing awareness of quality movement

  • Quality is more than the avoidance of error

  • Surgeons curiously excluded and/or non-participants in much work to date


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Scene Setting

  • To Err is Human*and

    Crossing the Quality

    Chasm**

  • Fundamental conflict with

    extreme risks and/or anxiety about

    professional liability issues

  • Relative success with SIP

  • Promise of reassertion of physician

    leadership

* National Academy Press, Washington D.C. 2000 **National Academy Press , Washington D.C,.2001


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Kentucky–A Favorable Platform for Special Study

  • University of Kentucky Medical Center (UKMC) alpha test site for National Surgical Quality Improvement Program (NSQIP/VA)

  • Early quality initiatives at Norton Hospital

  • Quality Surgical Solutions

  • Health Care Excel of Kentucky


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What is QSS?

  • 66 surgical specialists

  • 15 hospitals

  • 12 cities

  • 2 health plans

  • 43 protocols/current procedural technology (CPT) codes

  • BETTER PRACTICES


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Specialties Representedin QSS

  • General surgery to include trauma, digestive, vascular, colorectal, oncology, endoscopy

  • Orthopedic, otolaryngologic, urologic, gynecologic surgery


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Fundamental Hypotheses

  • Better quality surgical care is associated

    with reduced direct and overall expenses

  • Physician–led initiatives work

  • Commitment to prove concepts and

    ethically reward its doctors

  • Only effective public role is that of patient advocate


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Record ofAchievement Locally

  • Confidentiality of data

  • Prompt spread of agreed upon goals

  • Surgeons more prone to emulate other surgeons


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Create an Environment of Transformational Change

  • Innovate, report, refine, publish

  • Quality Improvement Conference

  • Value of the “near miss” and the praise of heroes and heroines

  • Examine routine and/or outdated printed orders


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Personal Role–Generally Helpful

  • Accept secondary and tertiary referrals without pain

  • Longstanding commitment to surgical excellence

  • Trained (partly or fully) many of Kentucky’s surgical specialists

  • Halo effect of QSS and having discussed it with hundreds of surgeons and administrative leaders

  • Personalized letters seeking surgeon support for SCIP through their hospitals


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Which Six… and Why?

A Lap GB D CABG/valve

B Hysterectomy E CR resections

C Major vascular F Total Knee/Hip

____________________________________

  • Not limited to Medicare beneficiaries

  • Primarily large volume hospitals

  • Significant complications and death


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Recruitment for SCIP Pilot

  • Group meetings for potential hospital participants and often their surgical specialists

  • Follow-up meetings, letters, and telephone calls

  • Recognition of the impact of current data submissions with invisible or meaningless feedback


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Conference Calls

  • Interest groups for each procedure

    • Lewis, Garrison, Polk, Van Vlack, and 2-5 specialists for the procedure

    • Prolonged sessions

    • Physicians very knowledgeable of current literature

    • Immediate agreement on process measures

      and feedback


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Detailed Developmentof QSS Involvement

  • Laborious development of doctor report forms

  • Alpha test of forms

  • Surgeon-leader reports

  • Begin to match hospital and surgeon reports

  • Broad-based education–laboratory for student success (LSS), grand rounds, collaboratives


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An Overview

  • Hospital contributions

    - Multiple procedures and surgeons

    • Honest sampling

    • Detailed, accurate abstraction

      - Tremendous enthusiasm

  • Surgeon contributions

    - Pre- and postop data

    • Detailed outcomes

    • Documentation of patient education


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Unique Opportunity to Match Hospital and Physician Reporting

  • More complete outcomes

  • Validation of accuracy for both methods of reporting

  • Consolidate surgeon and hospital performance into homogenous profile of quality


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Patient Education

  • Far better done in surgical specialists’ offices–how to document and promulgate

  • How can we quantitate and then assess quality?

  • Discussion


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Atmosphere that Promotes Patient Safety

  • Near miss and specific praise for the hero or heroine

  • Value of the process that targets the very rare disaster

    • The analogy between a plane crash and a pulmonary embolus–prophylaxis of the latter carries both risks and costs


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“We have achieved our goals in reining in the professional liability dragon.”

  • Physicians must now take the lead in identifying and solving problems of patient safety. We are now more protected than ever and can be the patient advocate we all want to be.

  • Allow doctors to clearly identify methods that provide improved quality.

    June, 2004 G.E. McGee, M.D., FACS


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Peer-Reviewed Publications liability dragon.”

  • Allen JW, DeSimone KJ. Valid peer review for surgeons working in small hospitals. Am J Surg 2002;184:16-18.

  • Allen JW, Hahm TX, Polk HC Jr. Surgeon-led initiatives cut costs and enhance the quality of endoscopic and laparoscopic procedures. J Soc Laparosc Surg 2003;7:243-247.

  • Galandiuk S, Rao MK, Heine MJ, et al. Mutual reporting of process and outcomes enhances quality outcomes for colon and rectal surgery. Surgery 2004; 136:833-841. [Presented at the Annual Meeting of the Central Surgical Association, March 2004].

  • McCafferty MH, Polk HC Jr. Addition of “near-miss” cases enhances a quality improvement conference. Arch Surg 2004;139:216-217.

  • Shively EH, Heine MJ, Schell R, et al. Practicing surgeons lead in quality care, safety, and cost control. Ann Surg 2004;239:752-762 [Presented at the Annual Meeting of the Southern Surgical Association, 2003].

  • Galandiuk S, Carter MB, Abby M, eds. When to Refer to a Surgeon. St. Louis, MO: Quality Medical Publishing, 2001.


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A multifaceted endeavor with the ultimate goal of significantly improving surgical care in the United States through the prevention of complications associated with surgery


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With a goal to reduce surgical complications and mortality 25% by 2010, the following estimated complications could be prevented annually for Medicare beneficiaries.

13,000 perioperative deaths

271,000 surgical complications

Hunt and Bratzler


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The Elements of SCIP 25% by 2010, the following estimated complications could be prevented annually for Medicare beneficiaries.

  • The Partnership

  • The Program

  • The Pilot


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The SCIP Partnership 25% by 2010, the following estimated complications could be prevented annually for Medicare beneficiaries.

A coalition of organizations interested in:

  • the improvement of surgical care through the reduction of post-operative complications

  • the development of performance measures and a data collection tool


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SCIP Partners 25% by 2010, the following estimated complications could be prevented annually for Medicare beneficiaries.

  • Agency for Healthcare Research and Quality (AHRQ)

  • American College of Surgeons (ACS)

  • American Hospital Association (AHA)

  • American Society of Anesthesiologists (ASA)

  • Association of periOperative Registered Nurses (AORN)


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SCIP Partners 25% by 2010, the following estimated complications could be prevented annually for Medicare beneficiaries.continued

  • Centers for Disease Control and Prevention (CDC)

  • Centers for Medicare & Medicaid Services (CMS)

  • Department of Veteran Affairs (VA)

  • Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

  • Institute for Healthcare Improvement (IHI)


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The SCIP Program 25% by 2010, the following estimated complications could be prevented annually for Medicare beneficiaries.

Technical elements, consisting of process measures (including specifications), outcome measures (including appropriate risk adjustment methods), and the “SPOT” database and electronic data collection tool


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The SCIP Pilot 25% by 2010, the following estimated complications could be prevented annually for Medicare beneficiaries.

A Medicare demonstration pilot designed to assess the feasibility of engaging private sector hospitals to reduce the incidence of post-operative morbidity and mortality


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Where Do We Go 25% by 2010, the following estimated complications could be prevented annually for Medicare beneficiaries.From Here?

Completion of pilot data collection

Final reports

Finalization of performance measures

for 8th SoW

National rollout


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For more information… 25% by 2010, the following estimated complications could be prevented annually for Medicare beneficiaries.

Visit the National SCIP Web site

http://www.medqic.org/scip

Contact the Kentucky Medicare QIO

[email protected]

(800) 300-8190

Contact Quality Surgical Solutions

http://www.qualitysurgical.com

(502) 583-7579

This material was prepared by Health Care Excel of Kentucky, the Medicare Quality Improvement Organization (QIO) of the Commonwealth, under contract with the Centers for Medicare & Medicaid Services (CMS), a federal agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Pub #HCEKI 01-2005


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