Intersection of Surgical Outcomes and Medical Education: The ACS Perspective (Division of Research and Optimal Patient Care) Clifford Y. Ko, MD MS MSHS FACS Director, Division of Research and Optimal Patient Care American College of Surgeons Professor of Surgery David Geffen School of Medicine at UCLA

No Disclosures

Dedicated to improving the care of the surgical patient and to safeguarding standards of care in an optimal and ethical practice environment

Four Guiding Principles of Continuous Quality Improvement 2. Right Infrastructure Staffing level/Specialists Equipment Checklists The Quality Processes 2. Right Infrastructure Staffing level/Specialists Equipment Checklists The Quality Processes 1.Standards Individualized by patient Backed by research 3.Rigorous Data From medical charts Backed by research Post-discharge tracking Continuously updated 4.Verification External peer-review Creates public assurance

ACS: 100 Years of Quality Improvement Bench to Bedside to Policy Minimum Standard for Hospitals COMMITTEE ON TRAUMA SSR

Current Issues in Surgery 1.Understanding the Metrics in Quality 2.Transparency/Public Reporting of Quality 3.Patient Experience 4.Real Data 5.Appropriateness 6.Sustained Quality Improvement – QI Process – Leadership/Team/Culture

Metrics: SCIP 1: Prophylactic antibiotic received within one hour prior to surgical incision 2: Prophylactic antibiotic selection for surgical patients 3: Prophylactic antibiotics discontinued within 24 hours after surgery end time (48 hours for cardiac patients) 4: Cardiac surgery patients with controlled 6 a.m. postoperative serum glucose 5: Surgery patients with appropriate hair removal 6: Colorectal surgery patients with immediate postoperative normothermia

Current Metrics Don’t Work So Well: SCIP has little correlation with Risk Adjusted Clinical Outcomes

“All Cause Harm”: Readmissions 11%, if no complications 36%, if complications

Readmission Rates Within 30 days for Colectomy No Cx DehisPE No Cx SSI Sup SSI Org Renal Insuff

Measuring Patient Experience with S-CAHPS Consumers Assessment of Healthcare Providers and Systems Surgical Patient Experience (6) 1. Surgeon Communication Before Your Surgery 2. Surgeon Communication After Your Surgery 3. Surgeon Care Before Your Surgery 4. Surgeon Care on the Day of Your Surgery 5. Surgeon Care After Your Surgery 6. Clerks and Receptionists at Surgeon’s Office

Procedure Any Cx Total SSI Total Pulm UTI Esophagectomy 47.33%16.46%29.22%2.06% Cystectomy 41.13%12.77%8.51%10.64% AAA 39.32%3.42%24.29%4.84% Pancreatectomy 35.31%18.75%11.35%6.73% Colectomy 29.85%11.65%12.45%4.84% Proctectomy 27.59%13.49%8.18%6.01% AoIliac bypass 24.22%7.32%7.49%2.96% Liver Rx 25.00%11.08%10.92%4.11% Abdominoplasty 20.93%11.63%0.00% Lung Rx 15.46%1.28%9.81%1.60% Endo AAA 11.83%2.35%3.91%1.63% Nephrectomy 13.24%1.78%3.16%3.36% Hysterectomy 9.60%2.32%1.79%4.32% REAL DATA Rates of Complications (w/o publication bias)

Outcome % occurring post D/C Median Day Colectomy Length of Stay 6 Mortality 18%10 Superficial Surgical Site Infection 53%9 Deep SSI 45%10 Organ Space SSI 39%11 Wound Disruption 34%10 Pneumonia 7.2%6 Cardiac Arrest 55%5 Myocardial Infarction 21%3 Renal Failure 15%6 DVT/PE 28/38%10/8 Bleeding requiring 4u transfusion 6%1 Sepsis 27%4 Failure to wean/Unplanned Reintub 14%2 Urinary Tract Infection 35%9 Following our patients for 30 days

Appropriateness: Essential for the Patient Provider Discussion

High Quality Surgical Care Best Practices/ Standards/ Implementation Feedback and Planning Data Collection/ Analysis Surgeons Leading QI

Scoring Teamwork: Teamwork in the Eye of the Beholder

A Start… “Quality in Training” Collaborative Pilot in NSQIP. A pilot project designed to bring together Training Facilities within ACS-NSQIP. Enable easy manipulation of data to provide standardized resident reports. Build ways to include quality evaluation, patient safety, and performance improvement that teach to real world use – Start to live it and understand it in training.

For more information on this ACS NSQIP Pilot Breakfast meeting tomorrow (Thursday) Time: AM Room: Aqua 312

Thank You

Intersection of Surgical Outcomes and Medical Education: The ACS Perspective (Division of Research and Optimal Patient Care) Clifford Y. Ko, MD MS MSHS FACS Director, Division of Research and Optimal Patient Care American College of Surgeons Professor of Surgery David Geffen School of Medicine at UCLA