Surgical Clinical Outcomes Assessment Program (SCOAP)

1. Surgical Clinical Outcomes Assessment Program (SCOAP)

2. Presenters Claudia Sanders Vice President, Policy Development WSHA Miriam Marcus-Smith Quality Improvement Program Director, Foundation for Health Care Quality Nancy Fisher, MD Medical Director Washington State Health Care Authority David Flum, MD SCOAP Medical Director Surgeon, University of Washington Medical Center Leigh Cooley Quality Improvement Director, Skagit Valley Hospital

3. Goals of Web Cast • To make sure hospitals are informed about SCOAP, currently under development at the Foundation for Health Care Quality • To make sure hospitals are preparing for the program • To provide an opportunity for hospitals to ask questions

4. Presentation Overview • Background and components • Rationale for SCOAP: surgical variability • SCOAP recommendations • SCOAP current status • Hospital concerns • Questions and discussion

5. Background and Components

6. COAP • Physician-led with all stakeholders included • CQIP status (Coordinated Quality Improvement Program) • Participation directed by HCA contracts with plans • Regular descriptive and risk-adjusted data reports

7. COAP (cont.) • Currently includes all coronary artery bypass grafts (CABG) and percutaneous heart procedures and programs • Will add valves in 2006

8. COAP (cont.) • Tracking of outlier status and coordinating QI activity has led to: • Improvements in use of best practices (arterial grafts) • Reduction in rate of adverse outcomes (prolonged time on ventilators)

9. SCOAP Background • HCA engaged Foundation for Health Care Quality (FHCQ) • HCA support of COAP, interest in SCOAP • Decision to proceed with SCOAP • Future contract requirements • Expansion to Medicare, Medicaid, private insurance • Methods • FHCQ partnership with UW • Literature review, analyses, stakeholder discussions

10. Rationale for SCOAP: Surgical Variability

11. Variability in Surgical Practices • There is significant variability in general surgery • Process • Outcome • Cost • Best Practices • There are “best practices” • “Best practices” can be encouraged

12. Variability in Other Industries

13. Variability in Other Industries • Risk falls below threshold • Variability is being addressed

14. Appendectomy • Most commonly performed emergency abdominal procedure • ~5800/yr • 15 percent misdiagnosed • 1 in 4 women of reproductive age

15. Appendectomy Variability in Outcome% Negative Appendectomy (NA), by Hospital

16. Gastric Bypass for Obesity Operations per Year in Washington

17. Variability in Adverse Outcome Gastric bypass for obesity by hospital

18. Colorectal Surgery • 5000/year • Adverse outcomes result in significant morbidity, mortality, and cost • Increasing use of laparoscopic colon resection has not been well studied

19. Colorectal Surgery Outcomes

20. Colorectal Surgery Outcomes Is SCOAP Worth It?

21. Is SCOAP Worth It? (cont.) • 2-5 years old−no clinical detail • “Apples and apples?”

22. Length of operation (hours) Procedure priority: elective Procedure method (Open vs. Laparoscopic) ASA class IV Lowest intra-op temperature Insulin administered in OR Highest periop BG Part removed: Ostomy: Anastomosis Anastomosis tested Pathology results confirm diagnosis Perioperative interventions: Heparin/LMWH within 2 hrs Intermittent pneumatic compression Beta blocker within 12 hrs Antibiotics within 60 min. Pain management within 24 hrs NGT RBC transfusion Mechanical ventilation post RR Is SCOAP Worth It? (cont.) Process Measures: Coloectomy & Procectomy

23. SCOAP Recommendations

24. SCOAP Goals • Create a system to evaluate and improve surgical quality • Define practice patterns • Risk adjusted outcomes • Track and reduce variability

25. Initial Focus on Three Procedures • Appendectomy • Colectomy/proctectomy • Bariatric

26. Procedure Selection Rationale • Performed widely • High cost, high volume and/or growing fast • High variability in process and outcomes • Complications in the inpatient setting

27. Program Features Similar to COAP • Physician leadership • Confidentiality • CQIP status and protection • Universal participation (eventual) • Existing infrastructure/ administration • Requirements to participate

28. Program Features Different from COAP • Funding sources • Initial • Ongoing • Coordinated QI activities

29. SCOAP Current Status

30. SCOAP Progress to Date • Secured funding from HCA to develop infrastructure • Data variables, forms, and definitions developed and tested • Report formats developed • Initial set of participating hospitals • Contracted with data management firm

31. Fred Bowers, MDKadlec Med. Center Leigh Cooley, RN, MNSkagit Valley Hospital Patch Dellinger, MDUniversity of Washington Med. Center Denise Dominik, RNSacred Heart Med. Center Michael Florence, MDSwedish Med. Center David Flum, MDUniversity of Washington Med. Center Eric Froines, MDGroup Health Cooperative Jerry Jurkovich, MDHarborview Med. Center Ben Knecht, MDWenatchee Valley Med. Center David Lauter, MDEvergreen Hospital Med. Center Paul Lin, MDSacred Heart Med. Center David Simonowitz, MDOverlake Hospital Med. Center Richard Thirlby, MDVirginia Mason Med. Center SCOAP Management Committee

32. SCOAP Timeline and Next Steps • Hospitals begin to collect and submit data • Secure program funding support effective January 2006 • Expand to additional hospitals this summer • Initial reports early 2006 • Bring in rural and critical access hospitals

33. SCOAP Hospital Roles • Early (2005) participants help shape SCOAP • Sign contract for data submission with Foundation • Work with SCOAP staff for training re variables, definitions, etc. • Submit data • Engage surgical and QI staff and leadership

34. SCOAP Costs • No fee in 2005 • Effective 2006, assume $15-$20 per case for budgeting • Staff time: 15-20 minutes per case for abstraction

35. Clinical FAQs • What are the alternatives? • SCIP/SIP • NSQIP • Centers of Excellence • Why are we focusing on process rather than outcome? • Balanced appraisal needed • Process is more actionable than outcome data

36. Administrative FAQs • Who will know a hospital’s results? • Hospitals and surgeons

37. Hospital Concerns

38. Hospital Concerns with SCOAP • Increased hospital reporting • Meetings regarding SCOAP • Costs/employee time • Extension of program to rurals • Hospital interest in not just reporting information, but desire for focus on quality improvement

39. Where We All Agree • Surgical COAP is consistent with increasing trend toward quality reporting • It will affect any hospital that performs the procedures and wishes to contract with insurers of state employees and will extend as other payers come on board • Information is available to help with planning and budgeting

40. POLL • How will SCOAP affect your hospital? • SCOAP will be very beneficial to improving surgical care. • SCOAP will be somewhat beneficial. • SCOAP is okay – an equal combination of benefit and burden. • SCOAP will be a reporting burden with little benefit. • SCOAP will be very burdensome with no benefit.

41. Questions Contact Information Leigh Cooley lcooley@skagitvalleyhospital.org ClaudiaSanders claudias@wsha.org Miriam Marcus-Smith Mmarcus-smith@qualityhealth.org

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