Surgical Care Improvement Project Performance Research Articles

Does Patient Safety Pay? Evaluating the Association Between Surgical Care Improvement Project Performance and Hospital Profitability.

Financial issues are top concerns for hospital executives. Evolving reimbursement structures focused on value provide an incentive to fully understand how patient safety performance and financial outcomes are connected. To that end, this study examines the relationships between Surgical Care Improvement Project (SCIP) measurements and hospital financial performance.Using multinomial logistic regression, we determined the association between hospital patient safety performances via analysis of eight prophylaxis data elements drawn from the archived Hospital Compare data. The measures are SCIP-Inf-1 (prophylactic antibiotic prophylaxis received within 1 hr prior to surgical incision), SCIP-Inf-2 (prophylactic antibiotic selection for surgical patients), SCIP-Inf-3 (prophylactic antibiotics discontinued within 24 hr after surgery end time), SCIP-Inf-4 (cardiac surgery patients with controlled 6 A.M. postoperative serum glucose management), SCIP-Inf-9 (urinary catheter removal postsurgery), SCIP-Inf-Card-2 (beta-blocker during the perioperative period), and SCIP-Inf-VTE-2 (venous thromboembolism prophylaxis). Data from the American Hospital Association provided two dimensions of organizational profitability: operating margin and net patient revenue. Our results indicate that improved hospital safety performance is associated with a relative risk of higher operating margin and net patient revenue, with some variation noted among the measures of patient safety. Our findings suggest that targeted improvement in patient safety performance, as evaluated in the Hospital Compare data, is associated with improved financial performance at the hospital level. Increased attention to safe care delivery may allow hospitals to generate additional patent care earnings, improve margins, and create capital to advance hospital financial position.

A Multidisciplinary Approach to Improving SCIP Compliance

The Surgical Care Improvement Project (SCIP) is a national program aimed at reducing perioperative complications and is a quality benchmark metric for Centers for Medicare and Medicaid Services. This study evaluates whether a multidisciplinary program improved an institution's compliance with SCIP measures. Analysis of the facility's performance data identified three key areas of SCIP noncompliance: 1) timely discontinuation of perioperative antibiotics and urinary catheters, 2) initiation of venous thromboembolism prophylaxis, and 3) perioperative beta blocker administration. Multidisciplinary teams collaborated with providers and department chairs in reviewing and enable SCIP compliance. Anesthesia staff managed preoperative antibiotics. SCIP-compliant order sets, venous thromboembolism pop-up alerts, and progress note templates were added to the electronic medical record. Standardized education was provided to explain SCIP requirements, review noncompliant cases, and update teams on SCIP performance. Data were captured from January 2009 to March 2014. Ten SCIP fallouts were reported for general surgery specialties in January 2013, when the SCIP compliance project launched. Specifically, colon-related surgery achieved 100 per cent compliance. Six months after implementation, overall SCIP compliance at our institution improved by 65 per cent (from 90.7-98.6% compliance).

Optimizing Care of Adults With Congenital Heart Disease in a Pediatric Cardiovascular ICU Using Electronic Clinical Decision Support*

The optimal location for postoperative cardiac care of adults with congenital heart disease is controversial. Some congenital heart surgeons operate on these adults in children's hospitals with postoperative care provided by pediatric critical care teams who may be unfamiliar with adult national performance measures. This study tested the hypothesis that Clinical Decision Support tools integrated into the clinical workflow would facilitate improved compliance with The Joint Commission Surgical Care Improvement Project performance measures in adults recovering from cardiac surgery in a children's hospital. Retrospective chart review comparing compliance pre- and post-Clinical Decision Support intervention for Surgical Care Improvement Project measures addressed in the critical care unit: appropriate cessation of prophylactic antibiotics; controlled blood glucose; urinary catheter removal; and reinitiation of preoperative β-blocker when indicated. Cardiovascular ICU in a quaternary care freestanding children's hospital. The cohort included 114 adults 18-70 years old recovering from cardiac surgery in our pediatric cardiovascular ICU. Clinical Decision Support tools including data-triggered alerts, smart documentation forms, and order sets with conditional logic were integrated into the workflow. Compliance with antibiotic discontinuation was 100% pre- and postintervention. Compliance rates improved for glucose control (p = 0.007) and urinary catheter removal (p = 0.05). Documentation of β-blocker therapy (nonexistent preintervention) was 100% postintervention. Composite compliance for all measures increased from 53% to 84% (p = 0.002). There were no complications related to institution of the Surgical Care Improvement Project measures. There was no in-hospital mortality. Compliance with the national adult postoperative performance measures can be excellent in a children's hospital with the help of Clinical Decision Support tools. This represents an important step toward providing high-quality care to a growing population of adults with congenital heart disease who may receive care in a pediatric center.

Perioperative antibiotics for surgical site infection in pancreaticoduodenectomy: Does the SCIP-approved regimen provide adequate coverage?

The Joint Commission Surgical Care Improvement Project (SCIP) includes performance measures aimed at reducing surgical site infections (SSI). One measure defines approved perioperative antibiotics for general operative procedures. However, there may be a subset of procedures not adequately covered with the use of approved antibiotics. We hypothesized that piperacillin-tazobactam is a more appropriate perioperative antibiotic for pancreaticoduodenectomy (PD). In collaboration with hospital epidemiology and the Division of Infectious Diseases, we retrospectively reviewed records of 34 patients undergoing PD between March and May 2008 who received SCIP-approved perioperative antibiotics and calculated the SSI rate. After changing our perioperative antibiotic to piperacillin-tazobactam, we prospectively reviewed PDs performed between June 2008 and March 2009 and compared the SSI rates before and after the change. For 34 patients from March through May 2008, the SSI rate for PD was 32.4 per 100 cases. Common organisms from wound cultures were Enterobacter and Enterococcus (50.0% and 41.7%, respectively), and these were cefoxitin resistant. From June 2008 through March 2009, 106 PDs were performed. During this period, the SSI rate was 6.6 per 100 surgeries, 80% lower than during March through May 2008 (relative risk, 0.204; 95% confidence interval [CI], 0.086-0.485; P = .0004). Use of piperacillin-tazobactam as a perioperative antibiotic in PD may reduce SSI compared with the use of SCIP-approved antibiotics. Continued evaluation of SCIP performance measures in relationship to patient outcomes is integral to sustained quality improvement.

Surgical care improvement project and surgical site infections: can integration in the surgical safety checklist improve quality performance and clinical outcomes?

IntroductionThe World Health Organization Surgical Safety Checklist (SSC) has been shown to decrease surgical site infections (SSI). The Surgical Care Improvement Project (SCIP) SSI reduction bundle (SCIP Inf) contains elements to improve SSI rates. We wanted to determine if integration of SCIP measures within our SSC would improve SCIP performance and patient outcomes for SSI. MethodsAn integrated SSC that included perioperative SCIP Inf measures (antibiotic selection, antibiotic timing, and temperature management) was implemented. We compared SCIP Inf compliance and patient outcomes for 1-y before and 1-y after SSC implementation. Outcomes included number of patients with initial post-anesthesia care unit temperature <98.6°F and SSI rates according to our National Surgical Quality Improvement Program data. ResultsImplementation of a SCIP integrated SSC resulted in a significant improvement in antibiotic infusion timing (92.7% [670/723] versus 95.4% [557/584]; P < 0.05), antibiotic selection (96.2% [707/735] versus 98.7% [584/592]; P < 0.01), and temperature management (93.8% [723/771] versus 97.7% [693/709]; P < 0.001). Furthermore, we found a significant reduction in number of patients with initial post-anesthesia care unit temperature <98.6°F from 9.7% (982/10,126) to 6.9% (671/9676) (P < 0.001). Institutional SSI rates decreased from 3.13% (104/3319) to 2.96% (107/3616), but was not significant (P = 0.72). SSI rates according to specialty service were similar for all groups except colorectal surgery (24.1% [19/79] versus 11.5% [12/104]; P < 0.05). ConclusionImplementation of an integrated SSC can improve compliance of SSI reduction strategies such as SCIP Inf performance and maintenance of normothermia. This did not, however, correlate with an improvement in overall SSI at our institution. Further investigation is required to determine other factors that may influence SSI at an institutional level.

Surgical Care Improvement Project Performance Measures: Good but Not Perfect

The process of development, implementation, and maintenance of national performance measures to assess the quality of healthcare is complex. Topics are selected for quality improvement on the basis of the impact of a clinical condition (mortality, morbidity, costs of care), presence of evidence-rated guidelines to identify best practices that can be measured, and known gaps in performance. Measures are developed after a careful review of guidelines with vetting from clinical experts in the field. Pilot testing occurs through review of samples of patient records with the target condition or with groups of providers who volunteer to participate. Implementation of the measures requires publication of detailed specifications for all data elements that must be collected to evaluate performance, and requires the programming of tools for data collection and analysis that can be utilized to evaluate performance. Maintenance of performance measures to ensure that the specifications are valid and consistent with newly developed medical knowledge requires ongoing review of published evidence. Just as postmarketing surveillance often reveals side effects of medications not identified during clinical trials, rolling out national performance measures to thousands of healthcare providers for implementation often brings to light issues with measure specifications and clinical scenarios not anticipated based on pilot testing. Changes to performance measure specifications often require additional field testing of data elements for

Strategies to promote reporting of Surgical Care Improvement Project (SCIP) measures: a pilot survey of anesthesia department leaders.

BackgroundThe Surgical Care Improvement Project (SCIP) is a quality improvement initiative focused on reducing surgical complications. Reporting SCIP performance measures helps determine whether hospitals receive the full payment update from the Centers for Medicare and Medicaid Services. Strategies in use by hospitals to motivate departmental participation in SCIP reporting are poorly understood.MethodsA 12-item pilot survey exploring strategies to promote reporting of SCIP measures was developed and mailed to department of anesthesiology chairs at 1,426 US hospitals. Descriptive statistics and χ2 analysis were used to summarize respondent and survey data.ResultsIn all, 29.5% of the sample responded to the survey, with 96.9% indicating SCIP participation; 62.5% participated primarily for voluntary reasons, and 4.2% reported an incentive from their hospital as the primary reason for participation.ConclusionsHospital strategies promoting physician participation in SCIP currently vary. A minority of survey respondents indicated that an incentive was used to encourage adherence to SCIP measures. Further research to optimize such strategies may support future efforts to improve perioperative care.

Contemporary Performance of U.S. Teaching and Nonteaching Hospitals

To compare the performance of U.S. teaching and nonteaching hospitals using a portfolio of contemporary, publicly reported metrics. The authors classified acute care general hospitals filing a Medicare Institutional Cost Report according to teaching intensity: nonteaching, teaching, or Council of Teaching Hospitals member. They compared aggregate results across categories for Hospital Compare process compliance, mortality, and readmission rates (acute myocardial infarction [AMI], heart failure, pneumonia); Surgical Care Improvement Project (SCIP) performance; compliance with Leapfrog standards; patient experience; patient services and key technologies; safety (computerized physician order entry, intensive care unit staffing, National Quality Forum safe practices, hospital-acquired conditions); and cost/resource utilization (Medicare-adjusted expense per case; Leapfrog efficiency and resource use standards). Availability of patient services and advanced technologies were associated with teaching intensity (P < .0001), as were most hospital safety metrics. Teaching intensity was favorably associated with SCIP performance, AMI and heart failure process scores, and mortality (P < .0001). It was unfavorably associated with higher AMI and pneumonia readmission rates (P < .0001) and lower scores for individual patient satisfaction measures. Costs per case were similar (P = .4194) across hospital categories after correction for federally allowed adjustments (case mix, wages, and low-income patient care). Teaching hospitals offer advanced clinical capabilities, educate the next generation of providers, care for disadvantaged urban populations, and are leaders in health care research and innovation. However, many stakeholders may be unaware of an additional value-relatively higher quality and safety in many areas, with similar adjusted costs.

Surgical Site Infection Prevention Policies and Adherence in California Hospitals, 2010

Surgical Site Infection Prevention Policies and Adherence in California Hospitals, 2010

Surgical Site Infection Prevention

The objective of this study was to evaluate whether the Surgical Care Improvement Project (SCIP) improved surgical site infection (SSI) rates using national data at the patient level for both SCIP adherence and SSI occurrence. The SCIP was established in 2006 with the goal of reducing surgical complications by 25% in 2010. National Veterans' Affairs (VA) data from 2005 to 2009 on adherence to 5 SCIP SSI prevention measures were linked to Veterans' Affairs Surgical Quality Improvement Program SSI outcome data. Effect of SCIP adherence and year of surgery on SSI outcome were assessed with logistic regression using generalized estimating equations, adjusting for procedure type and variables known to predict SSI. Correlation between hospital SCIP adherence and SSI rate was assessed using linear regression. There were 60,853 surgeries at 112 VA hospitals analyzed. SCIP adherence ranged from 75% for normothermia to 99% for hair removal and all significantly improved over the study period (P < 0.001). Surgical site infection occurred after 6.2% of surgeries (1.6% for orthopedic surgeries to 11.3% for colorectal surgeries). None of the 5 SCIP measures were significantly associated with lower odds of SSI after adjusting for variables known to predict SSI and procedure type. Year was not associated with SSI (P = 0.71). Hospital SCIP performance was not correlated with hospital SSI rates (r = -0.06, P = 0.54). Adherence to SCIP measures improved whereas risk-adjusted SSI rates remained stable. SCIP adherence was neither associated with a lower SSI rate at the patient level, nor associated with hospital SSI rates. Policies regarding continued SCIP measurement and reporting should be reassessed.

Adherence to Surgical Care Improvement Project Measures and the Association With Postoperative Infections

The Surgical Care Improvement Project (SCIP) aims to reduce surgical infectious complication rates through measurement and reporting of 6 infection-prevention process-of-care measures. However, an association between SCIP performance and clinical outcomes has not been demonstrated. To examine the relationship between SCIP infection-prevention process-of-care measures and postoperative infection rates. A retrospective cohort study, using Premier Inc's Perspective Database for discharges between July 1, 2006 and March 31, 2008, of 405 720 patients (69% white and 11% black; 46% Medicare patients; and 68% elective surgical cases) from 398 hospitals in the United States for whom SCIP performance was recorded and submitted for public report on the Hospital Compare Web site. Three original infection-prevention measures (S-INF-Core) and all 6 infection-prevention measures (S-INF) were aggregated into 2 separate all-or-none composite scores. Hierarchical logistical models were used to assess process-of-care relationships at the patient level while accounting for hospital characteristics. The ability of reported adherence to SCIP infection-prevention process-of-care measures (using the 2 composite scores of S-INF and S-INF-Core) to predict postoperative infections. There were 3996 documented postoperative infections. The S-INF composite process-of-care measure predicted a decrease in postoperative infection rates from 14.2 to 6.8 per 1000 discharges (adjusted odds ratio, 0.85; 95% confidence interval, 0.76-0.95). The S-INF-Core composite process-of-care measure predicted a decrease in postoperative infection rates from 11.5 to 5.3 per 1000 discharges (adjusted odds ratio, 0.86; 95% confidence interval, 0.74-1.01), which was not a statistically significantly lower probability of infection. None of the individual SCIP measures were significantly associated with a lower probability of infection. Among hospitals in the Premier Inc Perspective Database reporting SCIP performance, adherence measured through a global all-or-none composite infection-prevention score was associated with a lower probability of developing a postoperative infection. However, adherence reported on individual SCIP measures, which is the only form in which performance is publicly reported, was not associated with a significantly lower probability of infection.

Are surgical patients at risk of venous thromboembolism currently meeting the Surgical Care Improvement Project performance measure for appropriate and timely prophylaxis?

The US Surgical Care Improvement Project (SCIP) has approved two performance measures to improve venous thromboembolism (VTE) prevention. SCIP-VTE-2 measures the proportion of surgery patients who received appropriate VTE prophylaxis within 24 h prior to surgery to 24 h after surgery. This study assesses the current rate of achievement of SCIP-VTE-2 criteria using a retrospective data set of real-world surgical patients. The Premier Perspective database, which contains real-world data from >400 US hospitals, was queried (January 2004-December 2006) for in-patient hospital transactional billing records of surgical patients aged >or=18 years. The primary outcome was the proportion of patients achieving SCIP-VTE-2 requirements for appropriate and timely prophylaxis as per the SCIP-VTE-2 algorithm. Of the 149,785 patients included, 56.2% received appropriate prophylaxis and 52.7% achieved the SCIP-VTE-2 performance measure for both appropriate and timely prophylaxis. To conclude, this study highlights that VTE prophylaxis currently only meets SCIP-VTE-2 requirements in approximately half of real-world surgical patients. The use of retrospective analyses such as this hospital billing data analysis may assist hospitals in measuring their current and future performance in VTE prevention.