Examples of past projects undertaken by ISQIC hospitals:
Four prehabilitation modules are available for hospitals to implement: smoking cessation, nutrition, physical functioning, and cognitive preparedness.
Prior to program launch, hospitals will decide which prehabilitation modules they wish to implement for their colectomy and proctectomy patients. Hospitals may choose any or all prehabilitation modules, however ISQIC suggests hospitals participate in nutrition, at minimum. The modules your hospital chooses to implement will be referred to as your hospital’s prehabilitation “declared modules”. After your hospital declares which modules they will implement, declared modules will be implemented and abstracted for all laparoscopic, robotic, and open ACS NSQIP targeted colectomy and proctectomy CPT codes for the study period.
Toolkits are now available for download:
Comprehensive Venous Thromboembolism (VTE) Prophylaxis
The current, publicly reported venous thromboembolism (VTE) outcome measure (PSI-12) has significant flaws due to surveillance bias, and the VTE process measure (SCIP-VTE-2) only measures the provision of prophylaxis in the 24 hours before and after surgery.
The ISQIC Solution
ISQIC has developed and implemented a composite process measure of postoperative VTE prophylaxis that improves on the limitations of prior measures and is particularly useful to hospitals in identifying specific targets for improvement. The three components of the composite VTE prophylaxis process measure are the three widely accepted components of optimal postoperative VTE prophylaxis: 1) early ambulation (ordered and attempted at least once within the first 24 hours after surgery), 2) sequential compression devices (ordered, on the patient, and working at least once within in the first 24 hours after surgery), and 3) chemoprophylaxis (ordered at the correct dose and frequency throughout each patient’s entire hospitalization). For each component measure, there are reasonable clinical exceptions that would allow a patient to pass the measure even if one of the components was not completed. A patient only passes the composite measure if all three component measures are passed. Importantly, the measure can be adapted to focus on one component such as chemoprophylaxis, ensuring correct dose, timing, and delivery of all doses throughout the hospital stay. The composite VTE prophylaxis process measure can help hospitals identify their local, specific failures in VTE prophylaxis (e.g., ordering, administration, patient refusal, etc.), and also reliably benchmark and compare performance between hospitals.
Post-Discharge VTE Prophylaxis
According to the CDC, VTE is the leading cause of preventable hospital death in the United States. Each year, approximately 900,000 people in the U.S. are affected by blood clots (DVT/PE), of which approximately 50% are healthcare-associated (CDC Venous Thromboembolism, 2017). Surgery is a major risk factor for VTE, especially lower limb orthopedic procedures (total knee and hip arthroplasty specifically) and abdominal/pelvic surgery for cancer.
The ISQIC Solution
ISQIC has developed and implemented a best practice adherence (process) measure for post-discharge extended VTE chemoprophylaxis that is particularly useful to hospitals in identifying specific targets for improvement. The major components of the measure include indication, ordering of VTE chemoprophylaxis at the time of discharge, type of chemoprophylaxis ordered, and prescription duration (days). There are reasonable clinical exceptions that allow a patient to pass the measure even if post-discharge VTE chemoprophylaxis was not ordered. A patient only passes the measure if the appropriate type and prescription duration (number of days) of VTE chemoprophylaxis was prescribed at the time of discharge or if a reasonable clinical exception applies.
The post-discharge extended VTE chemoprophylaxis measure can help hospitals identify their local, specific failures in regards to appropriately prescribing post-discharge VTE chemoprophylaxis (e.g. type, duration, acceptable exceptions) and also reliably benchmark and compare performance between hospitals.
Improving Surgical Care and Recovery Plus
Enhanced Recovery Pathways
Enhanced Recovery Pathways (ERPs) are proven means of minimizing the physiological trauma of surgery to reliably shorten length of stay, decrease complications and costs, and improve patient experience. Institutions have used ERP programs to decrease length of stay by 1-2 days per patient, decrease complication rates by approximately 50%, save over $6,000 per patient, decrease 30-day re-admission rates by over 40%, and improve patient satisfaction scores.
Many people know this work by the name ERAS, or Enhanced Recovery After Surgery (ERAS). ERP is accomplished by:
Focusing on better education and management of patient expectations Minimization of fasting before and after surgery Minimizing opioids in lieu of opioid sparing pain medications Minimizing IV fluids Promoting early and frequent ambulation and convalescence
Implementing these changes to the way care is given requires transdisciplinary teamwork and buy-in. All providers and patients need to be speaking the same language to optimally implement ERP.
AHRQ Safety Program for Improving Surgical Care and Recovery
The Johns Hopkins Armstrong Institute, in collaboration with the American College of Surgeons (ACS), is conducting a national quality improvement initiative funded and guided by the Agency for Healthcare Research and Quality (AHRQ) titled Improving Surgical Care and recovery (ISCR). ISCR is a collaborative program to enhance the recovery of the surgical patient by supporting hospitals in implementing perioperative evidence-based pathways to meaningfully improve clinical outcomes, reduce hospital length of stay and improve the patient experience.
Improving Surgical Care and Recovery Plus
ISQIC is building on the ISCR initiative by strengthening hospitals’ readiness to implement ERP and providing additional implementation support and resources. ISQIC hospitals are completing a two-part self-diagnostic tool to assist them in identifying areas where the implementation core team and departments impacted by the pathway can be strengthened. The ISQIC Readiness Assessment Toolkit then provides tools to build and strengthen the areas identified in the assessment.
Opioid Reduction Initiatives
Over prescription of narcotics is common and retained surplus medication presents a readily available source of opioid diversion (Bates 2011). 1 in 20 people in the U.S. (ages 12 or older) reported using prescription painkillers for non-medical reasons in the past year (CDC Guidelines, 2016). Nearly half a million emergency department visits in 2009 were due to people misusing or abusing prescription painkillers (CDC Guidelines, 2016). Non-medical use of prescription painkillers costs health insurers up to $72.5 billion annually in direct health care costs (CDC Guidelines, 2016).
Create an opioid retrieval program Systematic changes to default order sets Automate prescription monitoring program inquiries Create best practices for prescribing patterns Physician, RN, patient education
Addressing Acute Surgical Pain
Emphasize use of non-narcotic pain treatment pathways Develop of transition pain services
Addressing Chronic Pain from Surgery
Improve transition to PCP Decrease use of narcotics with non-narcotic adjuncts
Improving the Science
Partner with the Illinois Prescription Monitoring Program (IL-PMP) Partner with private and public insurers Partner with pharmacies Share data among hospitals (inpatient pharmacy records) Develop physician and hospital-level reports Measure adverse drug events
Video-Based Technical Skills - Artisight for OR Video Capture
Laparoscopy and the advancement of video-capture capabilities have made it remarkably easy to record and analyze the details of an operation. In 2013, the New England Journal of Medicine article “Surgical Skill and Complications after Bariatric Surgery” demonstrated that scores from a video-based technical skills assessment were associated with patient outcomes.
Implemented within the Michigan Bariatric Surgery Collaborative, they used edited (20-40 minutes) videos of the key components of a Roux-En-Y-Gastric Bypass procedure performed by practicing bariatric surgeons. These videos were scored by other practicing bariatric surgeons according to the Objective Structured Assessment of Technical Skills (OSATS) rubric and then analyzed in aggregate. They found that better technical skill scores led to fewer complications. ISQIC hospitals participated in a pilot video-based coaching project for technical skills. Based on what we learned, we are now excited to offer additional opportunities for using video-based technical assessment for quality improvement, research, and much more!
Evaluating ISQIC Success
We received an R01 (5R01HS024516; PI: Bilimoria) from the Agency for Healthcare Research and Quality (AHRQ) to evaluate whether providing hospitals with a multi-component quality improvement collaborative improves surgical quality and safety and which of the 21 components contributes most to improving quality. Our research provides detailed insights into how hospitals adapt and implement a QIC to meet local needs and offers new knowledge by identifying the QIC components that are needed by hospitals to facilitate improvement beyond simply measuring outcomes. Ultimately our research addresses the broader need for generalizable models (e.g., tools and approaches) to evaluate how to improve implementation and effectiveness of QICs.
Our research uses mixed methods including site visits to member hospitals, surveys, interviews, and quantitative analyses of process and outcomes data. The site visits have generated local excitement about ISQIC, allowed us to take a deep dive into hospital and surgical culture, and given us valuable information on how the Coordinating Center can better support ISQIC.
Catheter-Associated Urinary Tract Infection Initiative (CAUTI)
CAUTI is the most common health care associated infection. Though morbidity and mortality may be low, a significant percentage of infections can be prevented.
CAUTI is a publicly reported measure that impacts a large patient population and can influence hospital reimbursement rates. Development of the program specifics are underway including:
Provider educational modules and procedure-specific recommendations for catheter placement to address judicious use of urinary catheters Best catheter insertion practices and examples of recommended kits Educational resources for the timely removal of urinary catheters Examples of EMR documents and templates so hospitals can easily audit proper catheter placement and removal