Improving Surgical Outcomes Through Surgeon-specific Reporting: A Quality Improvement Initiative

Area of Science:

• Surgical Quality Improvement
• Patient Safety
• Health Services Research

Background:

• Quality improvement programs are vital for surgical patient safety and outcomes.
• Administrative data alone has limitations for accurate surgical benchmarking.
• Tertiary care centers require effective strategies to optimize inpatient operations.

Purpose of the Study:

• To implement and evaluate a surgeon-specific, group-based strategy to improve surgical outcomes.
• To enhance mortality, length of stay (LOS), and readmissions for inpatient operations.
• To address limitations of administrative data by incorporating surgeon-specific performance metrics.

Main Methods:

• Utilized Vizient data to create a dashboard tracking individual surgeon LOS index, mortality index, and readmissions.
• Group outcomes data were updated monthly, with individual reports provided quarterly.
• Quality improvement programs were developed per surgery type by designated leaders, with practice-specific data presented monthly.

Main Results:

• Over three years (2021-2023), 33 surgeons performed 8145 inpatient operations.
• Mortality rate decreased significantly from 0.64% to 0.17% (P = 0.003).
• Length of stay (LOS) index reduced from 0.97 to 0.92 (P = 0.03), while procedure-related readmissions remained stable.

Conclusions:

• Surgeon-specific, group-based strategies can drive adoption of surgical protocols and improve patient outcomes.
• Collaborative, data-driven approaches are crucial for enhancing the quality of surgical patient care.
• This model demonstrates a successful framework for surgical quality enhancement in a tertiary care setting.