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SURGICAL PERSPECTIVE

apidly Expanding Demands on Hospital Qualityersonnel Threaten the Quality of Their Reports

iram C Polk Jr, MD, Steven Vallance, MD, PhD

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here has been considerable growth of honest and legiti-ate quality efforts in a variety of surgical specialties that

re now beginning to provide clinically meaningful data forirtually all surgical specialties. This effort is especially im-ortant in the United States, where 85,000 people havelective operations every day. The safe passage of patientshrough their surgical experience is just as important asecuring the safety of citizens at our nation’s airports, onighways, and in cities. It is long past time that surgery join

n and be accepted in the circle of medical specialties thatave developed legitimate and growing quality andafety parameters.1,2 Some of these parameters are beingromulgated by different organizations that have the bestnterest of patients at heart, not the least of which are theoint Commission on Accreditation of Healthcare Organi-ations and the Centers for Medicare and Medicaid Ser-ices, especially with its Surgical Care Improvement ProjectSCIP) criteria, to which we contributed pilot project datan 2004.3

In addition, virtually every hospital is associated with aata collection consortium of some type, often through thetate hospital associations and national entities. There isrowing interest in how much one can extrapolate fromayment claims data, even to the point of suggesting thateaningful quality performance data can be extracted

rom that same source.4,5 In the case of university hospitals,ata submission is often through Medicore the Universityealth Consortium,6 which has a powerful and efficient

atabank of a very large number of parameters for all sur-ical specialty operations.

hat is the problem?hy the concern? As recognition of these issues has be-

ome more frequent and substantive, the hospital qualityersonnel and their data entry associates are now inundatedith a massive amount of material to be recorded and en-

isclosure Information: Nothing to disclose.upported in part by a grant from the Physicians’ Foundation for Healthystems Excellence.

eceived March 5, 2008; Accepted May 9, 2008.rom the Department of Surgery and the Price Institute of Surgical Research, anduality Surgical Solutions, PLLC, University of Louisville, Louisville, KY.orrespondence address: Hiram C Polk Jr, MD, Department of Surgery,

fniversity of Louisville, Louisville, KY 40292.

6042008 by the American College of Surgeons

ublished by Elsevier Inc.

ered. The evolution of the quality officer, be it a nonmed-cal staff leader, a relatively senior nurse, or a medicalecords librarian, has been fairly characteristic. Typically,mall hospitals have selected a single individual who oftenunctions in multiple roles as the quality manager, and veryarge hospitals have a similar person who might have addi-ional support from one or more data entry clerks or qualityurses. Some larger hospitals, which have been more far-ighted and proactive, have formed their own quality teamsnd developed or borrowed processes for data collection,eview, and feedback.

Each hospital contributes its data to a variety of qualifiednd proprietary entities and for government overview.hese data are seldom reviewed by a physician and often

erve no further useful purpose. The tasks have simply ex-anded far beyond the rate at which additional personnelave been assigned to these duties. The purpose of thisrticle is to bring these issues to the attention of readers ando seek support (spelled out as additional qualified person-el) to help in the surgery quality effort in virtually everyospital. Consider, for example, a very small hospital wherehe quality officer may have to collect a number of Surgicalare Improvement Project7 criteria from orthopaedic op-

rations, colorectal resections, and hysterectomy proce-ures. Collected data include choice of antibiotic, timingf first administration, cessation or last dose administra-ion,8 maintenance of normothermia during operations,9

aintenance of prescribed �-blocker medication, andlood glucose monitoring.10 Medication reconciliationust be followed and determinations made as to whether

r not suspected myocardial infarction patients receive anspirin within an hour of arrival at a hospital and whetherr not suspected pneumonia patients receive an appropri-te antibiotic within a very few hours of arrival. Few data, ifny, are collected prospectively, although the surgical time-ut has been described in an expanded fashion, permittingurgeons and staff to perform quality indicators in real timend an opportunity for “preflight” correction of some over-ights.11 Extracting quality core measure data from hospitalharts, even with electronic assistance, is difficult. Addi-ionally, the vast majority of American hospitals still haveome type of paper medical records that require manualeview. Quality personnel are buried, literally, in trying toind the criteria they seek within the growing pages of paper

or even an uneventful surgical procedure.

ISSN 1072-7515/08/$34.00doi:10.1016/j.jamcollsurg.2008.05.005

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605Vol. 207, No. 4, October 2008 Polk and Vallance Effect of High Demands on Hospital Quality Staff

Because we have written frequently about thesessues11-13 and are in frequent contact with both nationalnd local institutions, it seems that there has been an enor-ous crescendo of cries for help from quality personnelithin the past few months. Again, a focal point is the

maller hospital, where there are one or two quality person-el trying to keep pace with elective surgical antibioticrophylaxis, timing of aspirins for heart attacks and anti-iotics for pneumonia, monitoring of hemoglobin A1c,nd completion of eye and foot examinations for patientsith diabetes mellitus. In fact, hospitals are just now be-

oming aware of how much they, in turn, are requiring ofheir quality staffs; only the far-sighted ones are choosing tout more money into quality measurement resources. Gov-rnment pay-for-performance proposals and delays makeatters worse.14 The cash flow implications of pay- or

onpay-for-performance are profound. The worst aspect ofhis scenario is that individuals who have chosen or ac-epted duties in the quality arena are as obsessive and com-ulsive as are most surgeons. They want to do a good job,nd they want to do it for the right reason.

The overt failure to be able to complete their day’s workn a reasonable amount of time and to provide quality datan quality performance has become an acute anachronismor many of them. We have first-hand knowledge of burn-ut and retention issues, an issue others have addressed asell.15 The lack of personnel who perform quality improve-ent is a surgical problem because these individuals cannot

o their jobs without the immediate support of surgeonsho must also recommend to organizational leaders theumber of adequate staff necessary to abstract and analyzeuality parameters that are being monitored in hospitals.e have noted some of the surrogates that are most obvious

nd have some reasonable likelihood to be associated withenuine quality outcomes.16 The National Surgical Qualitymprovement (NSQIP) Program at Veterans Affairs medi-al centers has the advantage of a fairly standard electronicedical record and quality nursing officers who have been

rained on the job during the past 15 years. As a result, theyave an almost simplistic but helpful approach to some ofhese outcomes and a view of its future.16-18 The Veteransffairs model does not usually apply in larger hospitals, and

t surely does not apply in smaller hospitals where the magicumber of “quality” staff is often one individual. Theseata offer opportunities for individual surgical specialists toee that their own profile accurately reflects the high qualityf their own practice.19

s help on the way?urgeons need to join and help the quality personnel andeadership in their hospitals determine which surgical pa-

ameters are most meaningful and which situations can be m

onitored more efficiently. We have already noted thealue of the surgical time-out in its expanded fashion.11 Inontrast, some proposed indices of quality care are falla-ious, meaningless, or both, and could be eliminated. Sev-ral include monitoring temperature and blood glucose inperations that are very brief (eg, less than an hour). Manyospitals have discovered very simple ways through theirharmacies to be sure that antibiotic prophylaxis is termi-ated within 24 hours. Many surgeons also review venoushromboembolism occurrences (although very rare afterlective surgery), and most provide mechanical devices pre-nd postoperatively. The ongoing obsession with not shav-ng the surgical site is one that continues to befuddle us.he most valid data that supported this point of view were

hose acquired nearly 40 years ago, when preoperative staysn the hospital were the norm and, on the evening beforeperation, “shave from nipples to knees” was a standardractice.20 Pustules could develop overnight, and particu-

arly, if one were doing refined, clean operations, such as aascular prosthetic graft, there were instances in which realroblems supervened. Currently, virtually no one is in theospital for a preoperative night, and the significance ofhis whole process and its evidence-based rationale hasisappeared.Not only do surgeons need to support our colleagues and

ampaign for additional staff devoted to the quality effort,ut we must also realize that overwhelmed workers pro-uce inaccurate data. This, then, produces fallacious infor-ation about patient care, whether it is for the purpose of

anners across the street in front of the hospital or forctual data submitted to Medicare and model pay-for-erformance programs.21 This is truly a here-and-now

ssue.Perhaps, what is more disappointing is the failure of

urgical leaders to more broadly use the quality data evolv-ng from their hospitals and their systems for internal qual-ty control and to honestly and regularly use internal datarom the surgical services to target performances ready formprovement. There are now easily queried data banks thatermit risk-adjusted comparison of surrogate measures andhysical and fiscal outcomes based on:

National or regional benchmarks;

Every type of inpatient procedure and a growing num-ber of ambulatory procedures;

Vast data on associated diagnoses, including thosepresent on admission; and

Uses of imaging and pharmacy services.

The proper and broader use of these data sources willring the private sector and university hospitals into align-

ent with the respected National Surgical Quality Im-

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606 Polk and Vallance Effect of High Demands on Hospital Quality Staff J Am Coll Surg

rovement Program process and permit every surgical staffnd specialty to properly compare their work with appro-riate standards. Our own best successes have been theeview of mundane performance measures with smallroups of specialty surgeons, highlighting the pros andons of their personal cases with all users of the operatingoom suites.

Quality professionals rely on and expect data analysisrom specialty surgeons, not only to make sense of nationalore measure parameters, but to also guide the institution’suality initiative. Along with our involvement and exper-ise in quality improvement, data management and analysisill become a catalyst, ultimately drawing more profession-

ls into quality departments. The protection of our pa-ients, the provision of quality care, and the support forhose hospital personnel who are helping define quality inhe 21st century represent one more duty of the completeurgeon.

EFERENCES

1. Shively EH, Heine MJ, Schell R, et al. Practicing surgeons leadin quality care, safety, and cost control. Ann Surg 2004;239:752–762.

2. Polk HC. Surgical quality and safety: The patient comes first.Am Surg 2007;73:538–542.

3. Vallance SR, Schell RH, Robbins RE. The practicing surgeon asa member of the quality-safety team. Am Surg 2006;72:1112–1114.

4. Fry DE, Pine MB, Jordan HS, et al. The hazards of using ad-ministrative data to measure surgical quality. Am Surg 2006;72:1031–1037.

5. Pine MB, Jordan HS, Elixhauser A, et al. Enhancement ofclaims data to improve risk adjustment of hospital mortality.JAMA 2007;297:71–76.

6. Nguyen NT, Hinojosa MW, Fayad C, et al. Laparoscopic sur-

gery is associated with a lower incidence of venous thromboem-

bolism compared with open surgery. Ann Surg 2007;246:1021–1027.

7. Centers for Medicare and Medicaid Services. Hospital quality initia-tives. Available at: http://www.cms.hhs.gov/HospitalQualityInits/10_HospitalQualityMeasures.asp. Accessed January 30, 2008.

8. Bratzler DW, Houck PM. Antimicrobial prophylaxis for sur-gery: an advisory statement from the National Surgical InfectionPrevention Project. Am J Surg 2005;189:395–404.

9. Kurz A, Sessler D, Lenhardt R. Perioperative normothermia toreduce the incidence of surgical-wound infection and shortenhospitalization. N Engl J Med 1996;334:1209–1215.

0. Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulintherapy in critically ill patients. N Engl J Med 2001;345:1359–1367.

1. Altpeter T, Luckhardt K, Lewis JN, et al. Expanded surgicaltimeout: a key to real-time data collection and quality improve-ment. J Am Coll Surg 2007;204:527–532.

2. Allen JW, DeSimone KJ. Valid peer review for surgeons workingin small hospitals. Am J Surg 2002;184:16–18.

3. Galandiuk S, Rao MK, Heine MJ, et al. Mutual reporting ofprocess and outcomes enhances quality outcomes for colon andrectal surgery. Surgery 2004;136:833–841.

4. Grissom TL. Early efforts with quality at Centers for Medicareand Medicaid Services and judicious use of its powers as a payor.Am Surg 2006;72:990–993.

5. Darcey T, Litaker DG. Data quality bias: an underrecognizedsource of misclassification in pay-for-performance reporting?Quality Management in Health Care 2008;17:19–26.

6. Polk HC Jr, Lewis JN, Garrison RN, et al. Process and outcomemeasures in specialty surgery: Early steps in defining quality.Bull Am Coll Surg 2005;90:8–15.

7. DePalma RG. Surgical quality programs in the Veterans HealthAdministration. Am Surg 2006;72:999–100.

8. McCafferty MH, Polk HC. Patient safety and quality in surgery.Surg Clin North Am 2007;87:867–881.

9. Mahid SS, Polk HC Jr, Lewis JN, et al. Opportunities for im-proved performance in surgical specialty practice. Ann Surg2008;247:380–388.

0. Cruse PJE, Foord R. A five-year prospective study of 23,649surgical wounds. Arch Surg 1973;107:206–210.

1. Rogers SO. The holy grail of surgical quality improvement:process measures or risk-adjusted outcomes? Am Surg 2006;72:

1046–1050.