Scott Ellner, Director of Surgical Quality at Saint Francis Hospital and Medical Center, Hartford | New surgical quality efforts

Q. Saint Francis has created the position of Director of Surgical Quality. What’s the impetus behind this new position?

A. Given recent healthcare reforms, reimbursement will increasingly be based on quality outcomes, not volume. In anticipation of this trend, major elements of the strategic plan at Saint Francis Hospital and Medical Center, BestCare for a Lifetime, focus on patient-centered surgical quality improvement. To assist this effort, the position … was created. 

Q. One of your responsibilities is oversight of performance improvement programs. What are some of the performance improvements being undertaken?

A. In 2007, Saint Francis began voluntary participation in the National Surgical Quality Improvement Program (NSQIP). It is an evidenced-based, risk-adjusted program sponsored by the American College of Surgeons, which provides the data base to capture surgical patient variables that are statistically analyzed by an independent metric organization.  The data are compared to national benchmarks and reported back to Saint Francis. Should an outcome be identified as “needs improvement,” an actionable framework is developed to implement process improvement. The NSQIP data have led to a hospital-wide initiative to reduce 30-day postoperative surgical complications. For example, NSQIP has assisted with the identification of opportunities to prevent hospital- acquired urinary tract infections.

Q. You are co-founder of the Connecticut Surgical Quality Collaborative? What is that and how widespread of a group is that? 

A. The Connecticut Surgical Quality Collaborative is an informal contingent of five Connecticut hospitals who participate in the National Surgical Quality Improvement Program for surgical process improvement. Importantly, these Connecticut hospitals collaborate to improve patient outcomes by sharing information on best practices. Our vision is to emulate a current working model in the state of Michigan, which has 32 participating hospitals in a formalized surgical collaborative. The Michigan Surgical Quality Collaborative has garnered financial support from a major health insurance company due to the successful reduction in post-operative morbidity and mortality. The Michigan experience is a pointed example of a small investment leading to improved patient care and reduced healthcare costs. 

Q. A study of the Department of Veterans Affairs seemed to show great improvement in post-operative mortality. It also showed a drop in length of hospital stays. Are lower healthcare costs a goal of improved surgical quality?

A. The history of the NSQIP program has its foundation in the Department of Veterans Affairs. In 1991, the VA developed standardized definitions for medical terms like pneumonia, acute renal failure, and sepsis. Over a 10-year period, evidence-based data were utilized to support the recognized medical terms in order to clearly classify variables and complications affecting patient outcomes. The NSQIP program was validated in the VA setting by significantly decreasing post-operative complications and death. Subsequently, NSQIP was adopted by private and university hospitals in 2004 and is now recognized as the “gold standard” surgical quality program by The Joint Commission.  Saint Francis has recently commenced an analysis of cost savings associated with surgical improvement quality initiatives. The results are pending. The Michigan Collaborative was able to demonstrate an annual $7.4 million in savings through their surgical quality collaborative for 2007.

Q. Are surgical quality rates available to the public for review? Can they use this information to determine what hospitals they will use?

A. The National Surgical Quality Improvement Program data are not widely distributed for public review at this point. At Saint Francis we have disclosed our data to contracted insurance companies to demonstrate our commitment to performance improvement initiatives. Raw data results can be misconstrued if not presented in a risk-adjusted cohort analysis. Evidence-based quality indicators are utilized for process improvement rather than for marketing strategies.   

Q. Are there downsides for hospitals participating in a program like this? Can regulators use the information collected against hospitals?

A. The only downside for a hospital to voluntarily participate in the NSQIP program is that it requires a monetary investment to implement the program. Yet, the financial return on investment is expected to be much greater through the improvement in patient outcomes and satisfaction. The American College of Surgeons supports NSQIP, which is the leading professional organization for surgeons. It audits NSQIP participating hospitals biannually to validate the data abstracted which ultimately leads to areas of improvement, even if a hospital is granted exemplary status. Furthermore, the American Board of Surgery requires general surgeons certified after 2005 to participate in a registry like NSQIP in order to maintain board certification status every three years. We encourage all Connecticut hospitals to gather data and share best practices.