Quality Improvement and Efficiency ofCare: Are Acronyms Really the Way of the Future?Conor P. Delaney, MD, PhD

Quality improvement has become an increasingly important focus of health care over thelast decade. In an effort to systematically improve quality, several organizations andprograms have been developed, each known by a different acronym. This article describesthe origins, mission, and methodology of the organizations and programs that have beenestablished to standardize performance and improve quality. The role of these programs inhealth care, and the way they affect individual surgeons in practice, is then discussed.

Semin Colon Rectal Surg 22:192-196 © 2011 Elsevier Inc. All rights reserved.

Ten years ago, the Institute of Medicine focused attentionon the fact that there were real issues in the quality of

health care being provided in this country.1,2 Although sig-nificant efforts have gone into improving quality since thattime, surgeons should be proud that they have been pioneersin this area for many decades. Many generations of surgeonshave participated in Mortality and Morbidity conferences, inan effort to direct attention to problems with day-to-day careand to teach future generations of surgeons how to focus onavoiding potential complications as they progress in theirown careers.

In recent times several organizations and programs havebeen established to try to improve the quality of care that isprovided to the American public. Some have been estab-lished through independent or national organizations, whileothers have been established by the medical community. Thenumber of these programs that exist has become challengingto keep track of, and for many there is an element of confu-sion as to which programs are beneficial to us as we practice.

This review briefly defines the history and mission of theorganizations and programs that have been established toimprove quality in health care and discusses how we can allstrive to provide high-quality efficient care that offers pa-tients, health care systems, and payers the optimal methodsto support health care in the increasingly difficult environ-ment in which we practice.

From the Institute for Surgery and Innovation, University Hospitals CaseMedical Center, Case Western Reserve University, Cleveland, Ohio.

Address reprint requests to: Conor P. Delaney, MD, PhD, Institute for Sur-gery and Innovation, University Hospitals Case Medical Center, CaseWestern Reserve University, Cleveland, OH 44106-5047. E-mail: conor.

delaney@uhhospitals.org

192 1043-1489/$-see front matter © 2011 Elsevier Inc. All rights reserved.doi:10.1053/j.scrs.2011.06.002

Quality Organizationsand ProgramsOrganizationsJoint Commission forAccreditation of Hospitals (JCAHO)At the time of its foundation in 1913, the American College ofSurgeons (ACS) had a stated objective of developing “a sys-tem of hospital standardization” (Table 1). Based on thiswork, and the 3200 hospitals approved by 1950, the JointCommission was founded in 1951, in collaboration with theAmerican Medical Association (AMA) and several medicalsocieties, as an independent, not-for-profit organizationwhose primary purpose was to provide voluntary accredita-tion for hospitals. In 1997, JCAHO started assessing perfor-mance and outcome measures. Since that time, they havecontinued to evolve systems for standardizing care acrosshospitals in the United States and have evolved to a system ofunannounced visits to assess hospital quality. In 2001,JCAHO announced core measures for hospitals for myocar-dial infarction, heart failure, pregnancy, and pneumonia,soon to be followed by Surgical Infection Prevention, whichbecame the Surgical Care Improvement Project in 2006.

Ambulatory Care Quality Alliance (AQA)The AQA was founded in 2004 when the American Academyof Family Physicians, the American College of Physicians,America’s Health Insurance Plans, and the Agency for HealthCare Research and Quality (AHRQ) came together to expe-ditiously improve performance measurement at the clinicianand group level, to collect and aggregate data in a meaningfulway, and reporting useful information to stakeholders aboutthe ambulatory care setting. Steering groups have been estab-

lished for each area, as well as an overall steering group.

O

AP

Quality improvement and efficiency of care 193

Surgical Quality Alliance (SQA)The SQA was established as a partnership between surgicalspecialties and anesthesia with a goal of bringing surgicalspecialties and anesthesiology together to define principles of

Table 1 Review of Principal Quality Improvement Organizatio

AcronymSponsoring or Main

Organization Da

RGANIZATIONSJCAHO Joint Commission Direct

visitsobse

SQA ACS No direasse

NQF National QualityFoundation

Recomgoal

AHRQ Agency for Health CareResearch and Quality

Multipl

QAROGRAMS:SCIP Partnership of

organizationsAdmini

NSQIP ACS Enterenurs

PQRI CMS Admini

Medicare hospitalscompare

CMS Admini

OPPE JCAHO Not fin

MOC ABCRS Self-re

surgical patient quality measurement in all surgical settings.

The SQA also plans to collate measures of surgical care qual-ity, assist in the development of meaningful tools for qualityimprovement, and evaluate the use of registries. As an impor-tant adjunct, the SQA hopes to support the medical societies

d Programs

pe Assessing Mission

unced Hospitals Independent accreditation of hospitals,founded by collaboration betweenthe ACS, physicians (ACP), theAHA, the AMA, and the CMA tocreate the JCAH, an independent,not-for-profit organization to providevoluntary accreditation for hospitals

a Qualitymeasures

To bring surgical specialties andanesthesiology together to defineprinciples of surgical patient qualityand to develop meaningful tools forsurgical quality improvement

QIetrics

Multiple To promote change through nationalpriorities and goals for qualityimprovement; endorsing nationalconsensus standards for measuringand publicly reporting performance;promoting the attainment of nationalgoals through education andoutreach programs

N/A AHRQ is part of the United StatesDepartment of Health and HumanServices, which supports researchto improve the outcomes and qualityof health care, improve costefficiency, reduce errors andcomplications, and improve access

Process A national partnership of organizationswith a goal of reducing theincidence of surgical mortality andmorbidity by 25% by 2010, includingAHRQ, ACS, AHA, American Societyof Anesthesiologists, AORN, CDC,VA, JACHO, and CMS

ined Outcome Prospective, validated database toquantify 30-day risk-adjustedoutcomes

Claims andprocesses

Program through CMS that offers upto a 2% incentive to physicians orphysicians’ groups for reporting inan effort to improve quality

Outcomes Public reporting of selected hospitaloutcomes on a searchable Web site.

Notfinalized

Planned ongoing program ofassessment, rather than evaluationas part of the 2 yearlyreappointment process

Outcomes Program of continuous professionaldevelopment created by theAmerican Board of Surgery, andother member boards of theAmerican Board of MedicalSpecialties

ns an

ta Ty

unannoand

rvation

ct datssed

mendss and m

e

strative

d by trae

strative

strative

alized

ported

by keeping up to date on quality-related initiatives underway

ditvdstNf

D 3%

194 C.P. Delaney

in the federal and private sectors, and coordinating our re-sponses to those initiatives. On several occasions, SQA has in-formed Center for Medicare and Medicaid Services (CMS) aboutinadequacies in endpoints being assessed for surgical care, in aneffort to improve the efficiency and clinical importance of databeing collected, and to ensure that all process measures beingassessed have true clinical benefits for patients.

National Quality Forum (NQF)The NQF was established to focus on quality improvementconsensus standards for measuring and reporting perfor-mance and to promote national quality goals by education.Its membership includes numerous health care stakeholders,which are grouped into 8 member councils: ConsumerCouncil (patient organizations); Health Plan Council; HealthProfessional Council (physician and nursing groups and so-cieties); Provider Organization Council (Hospitals); Public/Community Health Agency Council; Purchasers Council;Quality Measurement, Research and Improvement Council;Supplier and Industry Council. More than 250 separategroups are involved (http://www.qualityforum.org), and thenumber continues to increase. The NQF institutes variousprojects to improve specific components of care. As an exam-ple, because of data suggesting that almost 18% of all hospi-talizations result in readmission within 30 days, in 2008NQF started to focus on recommended hospital readmissionmeasures. This has resulted in the development of NationalStandards for Hospital Care for Outcomes and Efficiency,which will be published in the near future.

Agency for Health Care Research and QualityThis Agency is part of the Department of Health and HumanServices (DHHS), which is designed to sponsor research toimprove outcomes and efficiency of health care and to broadenaccess to health care. Grants can be submitted to AHRQ in asimilar fashion to National Institutes of Health for sponsoredresearch studies.

ProgramsSurgical Care Improvement Project (SCIP)In 2006, SCIP was founded through the support of severalgroups (Table 1), in an effort to reduce the incidence ofsurgical complications by 25% by 2010. The Project evalu-ates process measures based on level I evidence from priorrandomized trials. Hospitals forward administrative data onendpoints to third-party vendors, who clean and sort the databefore development of hospital, regional, and national met-rics of incorporation into practice. The data are reported andultimately become part of the Joint Commission Annual Re-

Table 2 Changes in SCIP Outcomes from Joint Commission’s

Performance Measure 2005 20

Antibiotics within 1 h of incision 72.2% 78%Appropriate antibiotic use N/A N/

iscontinuation within 24 h 61.5% 65.

port.3 The 2009 report demonstrates improvement in pneu-

monia, cardiac, and all process measures being assessed. Thesurgical process measures and levels of change are outlined inTable 2.

Physician Quality Reporting Initiative (PQRI)The 2006 Tax Relief and Health Care Act required the estab-lishment of a reporting system with the potential of incentivepayments for eligible professionals (EP). Annual updates torules are published in the Federal Register. Data on individ-ual measures or groups of measures can be reported directlyto CMS on Part B claims; to a PQRI registry; or to CMSthrough a validated Electronic Health Care Record program.EPs who report these data will qualify for a PQRI incentivepayment equivalent to 2% of their Medicare Part B payments.Unfortunately, much of the PQRI system is based on claimsdata, and therefore, it is unclear that quality of care will beimproved. The SQA continues to lobby for the PQRI systemto include data from surgical data registries, rather than bill-ing data, as these might help improve quality.

National Surgical QualityImprovement Project (NSQIP)The ACS National Surgical Quality Improvement Program(ACS NSQIP) is the first nationally validated, risk-adjusted,outcomes-based program to measure and improve the qual-ity of surgical care. Based on concerns about the quality ofcare in the Veteran’s Administration (VA) system, Congressmandated the VA to report their outcomes in a risk-adjustedmanner.4 Preoperative, intraoperative, and postoperative

ata are collated for a sampling of cases performed in thosenstitutions that employ a specially trained nurse data collec-or (surgical clinical reviewer). Data are collected for 136ariables. Reliability audits are performed to ensure quality ofata. Work continues to develop specific NSQIP datasets forubspecialties, such as colorectal. There is now an extensiverack record of publications demonstrating outcomes withSQIP.5 Interesting work suggests that simpler datasets, of as

ew as 5 endpoints, may accurately predict quality of care.6

Medicare Hospitals CompareMedicare, through DHHS, now continuously publishes datafrom participating hospitals on the Web site http://www.hos-pitalcompare.hhs.gov/, reporting for the previous calendaryear. Data can be searched by location and procedure type.For instance, inserting a city, “surgical procedures,” “abdo-men,” and “bowel” gives a list of institutions in that regionperforming such procedures. Data are then reported on Pro-cess of Care Measures (based on SCIP); Outcomes of caremeasures (mortality and readmission of reported); Use of

l Report, 2009, for Performance Measures for Colon Surgery

2007 2008Improvement Since

Inception (%)

82.4% 87.6% 15.475.7% 84.3% 8.674.8% 80.4% 18.9

Annua

06

A

Medical Imaging; Survey of Patient Experiences (physician

U

ratfi

Quality improvement and efficiency of care 195

and nurse assessment by patients, cleanliness, etc); andMedicare payment and volume. These can be viewed com-paring up to 3 hospitals and are given compared to average inthe nation and in the state.

Ongoing Practice Professional Evaluation (OPPE)The Joint Commission has proposed a system of OPPE,where rather than having 2 yearly reappointment processes,physicians would be evaluated by an ongoing process. This isstill being discussed and evaluated as a performance assess-ment system. Many questions remain to be answered aboutsuch a process. These include the following: who will beresponsible for review of data (department chair, a creden-tials committees?); how often would evaluation be performed(should be more frequent than annual to be ongoing); whatdata would be collected; how will data be incorporated intophysicians data files; would this be by review of charts, ordirect physician review? As of March 15, 2010, no final de-cisions had been made about this form of assessment.

Maintenance of Certification (MOC)The American Board of Medical Specialties developed MOCas a system of continuous professional development for theirconstituents. This goes beyond the 10-year interval recertifi-cation that surgeons and other physicians must perform. Thisis a program developed by surgeons and for surgeons, with agoal of coordinating its requirements with state licensingboards and other interested parties. MOC is divided into 4parts. Part 1 is maintenance of professional standing throughmaintenance of an unrestricted medical license, hospitalprivileges, and satisfactory references. Part 2 is the process oflifelong learning and self-assessment through continuing ed-ucation and periodic self-assessment. Part 3 is cognitive ex-pertise based on examination performance. Part 4 is evalua-tion of performance in practice through tools, such asoutcome measures and quality improvement programs, andthe evaluation of behaviors, such as communication and pro-fessionalism.

Where Do TheseSystems Fit in Clinical Practice?We practice in a time where medical care and outcomes arebeing scrutinized as never before, and the emphasis on elec-tronic records and tracking of data continuously increases. In2009, the President signed the Health Information Technol-ogy for Economic and Clinical Health Act (HITECH Act) intolaw. This provides US$9 billion over 4 years to providers whoincrease their implementation of appropriate informationtechnology in their practices. Grants, loans, and direct incen-tive payments will be used with a goal of reducing overall costof health care, while improving efficiency.

Such efforts should be applauded, as we all strive to im-prove the quality of care that we offer our patients. As out-lined in the sections above, a large number of programs havebeen developed to acquire information on health care out-comes and apply it to improve care. What remains difficult to

prove is how these programs effectively improve quality, and

whether the programs are worth the significant effort andexpense that each entails. Much of the data being collectedduplicates other systems, and much evaluates processes ofcare, rather than outcomes. This has led to some lack ofclarity and frustration on the part of providers who see muchof what is being performed as “big brother” looking over ourshoulders and concerns whether systems that assess pro-cesses actually improve outcomes.7

Many of these data are useful for patients, who can see howdifferent institutions perform. A concern for individual phy-sicians, hospitals, and physician groups is whether these dataare appropriately risk-stratified and account for differing lev-els of complexity of care. Whether we like it or not, such dataare now being published on Web sites, such as the MedicareHospitals Compare program. The Society for Thoracic Sur-gery has been extremely proactive and has developed its ownrisk-stratified database. Approximately 20% of cardiac sur-gery cases are now voluntarily reported, and data from thiswere recently published in Consumer Reports and discussed inan online editorial in the New England Journal of Medicine,8

using performance measures approved by the NQF.What we must remember is that our goal should be to

continue to improve that quality of care that we provide.Quality care is a combination of many things, but includesdoing the correct procedure for the correct diagnosis, per-forming it in as efficient a way as possible, and minimizingcomplications for the patient. Complications not only ad-versely impact the patient, but they significantly increase thecost of provision of care.9 This is becoming increasingly im-portant for hospitals as reimbursement for care will not coverpayment for complications and readmission. This is also ofimportance as technology becomes more expensive. Recentarticles on robotic prostate surgery suggest that it may be nobetter than open surgery,10 even though it costs an extra

S$2.5 billion per year.We have tried to maximize care efficiency using enhanced

ecovery pathways to facilitate patient recovery after surgerynd safely shorten hospital stay.11 In suitable cases, the addi-ion of minimally invasive surgical approaches improves ef-ciency over standard open surgery.12 At a national level,

similar benefits can be achieved with laparoscopy.13 Use ofstandardized discharge criteria has permitted early dischargeof high percentages of patients, allowing us to define patientswho are doing well, and those who are likely to do less well,and who should therefore be observed for an additional timein hospital.14

In summary, we have the tools available to help patientsrecover rapidly after surgery, combining appropriate use oftechnology with optimal care pathways for our patients. Wehave multiple programs and organizations reporting on theprocesses that we use, and some of the outcomes that can beobtained. Surgical societies should continue to guide anddevelop accurate reporting endpoints that provide meaning-ful data on outcomes. This is likely to be based on surgeon-specific registries that use datapoints specific to different sur-gical specialties. Scott Jones, Brown, and Opelka describedsuch registries in 2005 that would report on a phased intro-

duction of standards that would assure the surgeons’ role in

196 C.P. Delaney

quality and safety, including confirmation of operative site,preoperative time out, appropriate postoperative care, in afirst phase.15 A second phase would report process measures,before the third and final phase, which would focus on theoutcomes of care. As we get closer to this final phase, we mustcome to consensus about the datapoints that we should col-lect and perform comparative effectiveness research to con-firm their validity before using them as benchmarks to com-pare individual surgeons.

References1. Corrigan J: Crossing the Quality Chasm. Washington, National Acad-

emies Press, 20012. Kohn LT, Corrigan JM, Donaldson MS (eds): To Err Is Human. Wash-

ington, National Academies Press, 19993. The Joint Commission’s Annual Report on Quality and Safety, 2009

(http://www.jointcommission.org/Library/annual_report)4. Khuri SF, Daley J, Henderson WG: The comparative assessment and

improvement of quality surgical care in the Department of VeteransAffairs. Arch Surg 137:20-27, 2002

5. Dimick JB, Osborne NH, Hall BL, et al: Risk adjustment for comparinghospital quality with surgery: How many variables are needed? J AmColl Surg 210:503-508, 2010

6. Shiloach M, Frencher SK Jr, Steeger JE, et al: Toward robust informa-

tion: Data quality and inter-rater reliability in the American College of

Surgeons National Surgical Quality Improvement Program. J Am CollSurg 210:6-16, 2010

7. Stulberg JJ, Delaney CP, Neuhauser DV, et al: Adherence to surgicalcare improvement project measures and the association with postop-erative complications. JAMA 303:2479-2485, 2010

8. Ferris TG, Torchiana DF: Public release of clinical outcomes data—Online CABG report cards. N Engl J Med 363:1593-1595, 2010. Avail-able at: http://www.nejm.org/doi/pdf/10.1056/NEJMp1009423

9. Dimick JB, Chen SL, Taheri PA, et al: Hospital costs associated withsurgical complications: A report from the private-sector National Sur-gical Quality Improvement Program. J Am Coll Surg 199:531-537,2004

10. Hu JC, Gu X, Lipsitz SR, et al: Comparative effectiveness of minimallyinvasive vs open radical prostatectomy. JAMA 302:1557-1564, 2009

11. Delaney CP, Fazio VW, Senagore AJ, et al: Fast-track post-operativemanagement protocol for patients with high co-morbidity undergoingcomplex abdominal and pelvic colorectal surgery 88:1533-1538, 2001

12. Delaney CP, Kiran RP, Senagore AJ, et al: Case-matched comparison ofclinical and financial outcome after laparoscopic or open colorectalsurgery. Ann Surg 238:67-72, 2003

13. Delaney CP, Chang E, Senagore AJ, et al: Clinical outcomes and re-source utilization associated with laparoscopic and open colectomyusing a large national database. Ann Surg 247:819-824, 2008

14. Delaney CP: Outcome of discharge within 24-72 hours of colorectalsurgery. Dis Colon Rectum 51:181-185, 2008

15. Jones RS, Brown C, Opelka F: Surgeon compensation: “Pay for perfor-mance,” the American College of Surgeons National Surgical QualityImprovement Program, the Surgical Care Improvement Program, and

other considerations. Surgery 138:829-836, 2005