Macro vs micro level surgical quality improvement: a regional collaborative demonstrates the case for a national...

The Florida Surgical Care Initiative (FSCI) is a quality improvement collaborative of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) and the Florida Hospital Association. In the wake of a dramatic decrease in complications and cost documented over 15 months, we analyzed the semiannual measures reports (SAR) to determine whether this improvement was driven by specific institutions or was a global accomplishment by all participants.

Reports from NSQIP were analyzed to determine rank change of participants. Odds ratio (OR) of observed-to-expected incidence of the 4 FSCI outcomes (catheter-associated urinary tract infection [CAUTI], surgical site infection [SSI], colorectal, and surgery in patients older than 65 years) were used to assess individual and group performance. Data from SAR 2 (October 2011 to April 2012) were compared with data from SAR 3 (May to July 2012). Poorly performing hospitals were tracked to determine evidence of improvement. Individual facility performance was evaluated by determining proportion of hospitals showing improved rank across all measures.

Fifty-four hospitals were evaluated. SAR 2 reported 28,112 general and vascular surgical cases; SAR 3 added 10,784 more. The proportion of institutions with OR < 1 for each measure did not change significantly. Only urinary tract infection and colorectal measures demonstrated increased number of hospitals with OR < 1. Each institution that was a significant negative outlier in SAR 2 demonstrated improvement. Three of 54 hospitals demonstrated improvement across all 4 measures. Of 15 hospitals with improved performance across 3 measures, all included elderly surgery.

The increase in quality achieved across this population of surgical patients was the result of a quality assessment process driven by NSQIP rather than disproportionate improvement of some raising the bar for all. The NSQIP process, applied collaboratively across a population by committed institutions, produces dramatic results.