Intersection of Surgical Outcomes and Medical Education:

The ACS Perspective(Division of Research and Optimal Patient

Care)

Clifford Y. Ko, MD MS MSHS FACSDirector, Division of Research and

Optimal Patient CareAmerican College of Surgeons

Professor of SurgeryDavid Geffen School of Medicine at UCLA

No Disclosures

Dedicated to improving the care of the surgical patient and to

safeguarding standards of care in an optimal and ethical practice

environment

Four Guiding Principles of Continuous Quality Improvement

2. Right Infrastructure• Staffing

level/Specialists• Equipment• Checklists• The Quality

Processes

1. Standards• Individualized by

patient• Backed by research

3. Rigorous Data• From medical charts• Backed by research• Post-discharge tracking• Continuously updated

4. Verification• External peer-

review• Creates public

assurance

ACS: 100 Years of Quality ImprovementBench to Bedside to Policy

1917

1913 1922 1950

1951

1998

2004

2005

2011

Minimum Standard for

Hospitals

COMMITTEE ON TRAUMA

SSR

Current Issues in Surgery1. Understanding the Metrics in Quality2. Transparency/Public Reporting of

Quality3. Patient Experience4. Real Data 5. Appropriateness6. Sustained Quality Improvement

–QI Process–Leadership/Team/Culture

Metrics: SCIP1: Prophylactic antibiotic received within

one hour prior to surgical incision2: Prophylactic antibiotic selection for

surgical patients 3: Prophylactic antibiotics discontinued

within 24 hours after surgery end time (48 hours for cardiac patients)

4: Cardiac surgery patients with controlled 6 a.m. postoperative serum glucose

5: Surgery patients with appropriate hair removal

6: Colorectal surgery patients with immediate postoperative normothermia

Current Metrics Don’t Work So Well: SCIP has little correlation with Risk Adjusted Clinical

Outcomes

“All Cause Harm”: Readmissions

• 11%, if no complications

• 36%, if complications

Readmission Rates Within 30 days

for Colectomy

No Cx

Dehis PE

No CxSSISup

SSIOrg

RenalInsuff

Measuring Patient Experience with S-CAHPS

Consumers Assessment of Healthcare Providers and Systems

Surgical Patient Experience (6)1.      Surgeon Communication Before Your Surgery2.      Surgeon Communication After Your Surgery3.      Surgeon Care Before Your Surgery4.      Surgeon Care on the Day of Your Surgery5.      Surgeon Care After Your Surgery6.      Clerks and Receptionists at Surgeon’s Office

www.cahps.ahrq.gov

Procedure Any Cx

Total SSI

Total Pulm

UTI

Esophagectomy 47.33%16.46

% 29.22% 2.06%

Cystectomy 41.13%12.77

% 8.51% 10.64%AAA 39.32% 3.42% 24.29% 4.84%

Pancreatectomy 35.31%18.75

% 11.35% 6.73%

Colectomy 29.85%11.65

% 12.45% 4.84%

Proctectomy 27.59%13.49

% 8.18% 6.01%AoIliac bypass 24.22% 7.32% 7.49% 2.96%

Liver Rx 25.00%11.08

% 10.92% 4.11%

Abdominoplasty 20.93%11.63

% 0.00% 0.00%Lung Rx 15.46% 1.28% 9.81% 1.60%

Endo AAA 11.83% 2.35% 3.91% 1.63%Nephrectomy 13.24% 1.78% 3.16% 3.36%Hysterectomy 9.60% 2.32% 1.79% 4.32%

REAL DATARates of Complications (w/o

publication bias)

Outcome

% occurring post D/C

Median Day

Colectomy Length of Stay 6Mortality 18% 10Superficial Surgical Site Infection 53% 9Deep SSI 45% 10Organ Space SSI 39% 11Wound Disruption 34% 10Pneumonia 7.2% 6Cardiac Arrest 55% 5Myocardial Infarction 21% 3Renal Failure 15% 6DVT/PE 28/38% 10/8Bleeding requiring 4u transfusion 6% 1Sepsis 27% 4Failure to wean/Unplanned Reintub

14% 2

Urinary Tract Infection 35% 9

Following our patients for 30 days

Appropriateness: Essential for the Patient Provider Discussion

High Quality Surgical Care

Best Practices/Standards/

Implementation

Feedbackand

Planning

Data Collection/Analysis

Surgeons Leading QI

88%

48%

0

10

20

30

40

50

60

70

80

90

100

Surgeons ratingteamwork

Nurses ratingteamwork

% R

atin

g q

ual

ity

of

colla

bo

rati

on

&

com

mu

nic

atio

n h

igh

or

very

hig

h

Scoring Teamwork:Teamwork in the Eye of the Beholder

A Start…

• “Quality in Training” Collaborative Pilot in NSQIP .

• A pilot project designed to bring together Training Facilities within ACS-NSQIP.

• Enable easy manipulation of data to provide standardized resident reports.

• Build ways to include quality evaluation, patient safety, and performance improvement that teach to real world use– Start to live it and understand it in training.

For more information on this ACS NSQIP Pilot

Breakfast meeting tomorrow (Thursday)

Time: 630-800AM Room: Aqua 312

Thank You

Intersection of Surgical Outcomes and Medical Education:

The ACS Perspective(Division of Research and Optimal Patient

Care)

Clifford Y. Ko, MD MS MSHS FACSDirector, Division of Research and

Optimal Patient CareAmerican College of Surgeons

Professor of SurgeryDavid Geffen School of Medicine at UCLA