By Dennis Jah, University of Massachusetts - Lowell
I. PROBLEM STATEMENT
What is the best approach to reduce post operative complications or deaths after inpatient surgery that will result into cost savings and improvement in the quality of care in US hospitals?
II. BACKGROUND
Surgical operations are necessary and indispensible in the delivery of care. These operations save lives or correct any number of disorders, injuries, diseases but they are not without risk. According to the Surgical Care Improvement Project (SCIP), of the nearly 30 million surgeries performed each year in the United States, a significant percentage results in preventable often life threatening complications.[1]
Since the Institute of Medicine (IOM) hallmark report “To Err is Human: Building a Safer Health System” was released, the issues of medical errors and other preventable complications have taken center stage. Released 1999, the report revealed that medical errors are responsible for between 44, 0000 to 98,000 deaths annually with an estimated annual cost of all adverse events ranging from $38 - $50 billion annually[2]. The report also reveals that a study of 44,603 surgical patients at a large medical center during a 13 year period showed that 5.4% of patients experienced a complication and 7.5% of the 749 cases in which the patient died were related to errors. Considering the lowest estimates or best case scenario, this will mean that one million surgical patients experience an adverse event every year or more than 2,700 times a day.
In 1991, the Harvard Medical Practice Study reported 1,133 preventable adverse events on the basis of more than 30,000 hospital records in which 48% were related to surgeries. For malpractice claims from a health system within the Department of Veteran Affairs (VA), it is reported that 18% of negligent adverse events were surgical and accounted for 20% of deaths.[3]
State and national policy makers have realized the importance of taking steps to reduce errors and complications that would otherwise be prevented not only to fight for patients who suffers the most as a result but also as a way of addressing increasing healthcare expenditures. Many interventions have been put into place by various stake holders in reducing surgical complications because as Donald Berwick, a leading voice of healthcare quality care once put it, when complications are reduced, “everyone wins.”
III. LANDSCAPE
Reducing postoperative complications is one area where all involved tend to agree that on top of loss of lives, there is huge cost associated with poor care or the lack of quality care. It is a no win situation for patients, providers, payers and malpractice insurance companies when post operative complications do occur. So, all have vested interests in reducing preventable complications and adverse events. With varying interests, the landscape is favorable for the adoption of an intervention that would address the problem of post surgical complications and deaths.
IV. KEY STAKEHOLDERS
When complications occur, patients suffer the most since they go through pain and sometimes even death as a result. But the major stakeholders are providers - physicians and hospitals that stand to lose money, practice license or accreditation as a result of high incidence of surgical complications. Other stakeholders are third party payers, liability insurance companies and accreditation organizations. Where there are fewer to no complications at all, they all stand to gain. For patients, fewer or no complications mean faster recovery time, shorter hospital stays and faster time to get back on their feet. Doctors rating system is gaining wider popularity across states. More complications for physicians affect their ratings which also make their malpractice insurance premiums to soar. If postoperative complications are reduced, physicians’ risk of losing their license or getting sued is reduced. As payers are now tying reimbursement with quality care, fewer complications for hospitals mean lower cost and more certainty to be reimbursed for the care they provide. And both physicians and hospitals will have enhanced reputation for quality.
According to a June 2006 Journal of American College of Surgeons article entitled “Who Pays for Poor Surgical Quality? Building a Business Case for Quality Improvement,” reimbursement for patients without complications estimated at $14,266 exceeded hospital costs ($10,978), generating an average hospital profit of $3,288 and a profit margin of 23%. Conversely, when complications occurred; hospitals still receive reimbursement in excess of their costs, but the profit margin declined to about 3.4%. Complications, it stressed were always associated with and increased cost to healthcare payers - an average increase in reimbursement of 7,645 per patient.[4]
When complications are reduced and doctors are not sued (more frequently), they will continue to pay their premiums while liability insurance companies will not have to pay back claims more frequently; accrediting organizations will also look good and experience payoff in the realm of ensuring quality care. Patients will be happy as they don’t have to suffer as a result of mistakes and poor quality of healthcare they receive.
V. KEY FACTORS
While patients, providers, third party payers, liability insurance companies and all other stakeholders have everything to gain from reduced surgical complications, hospitals are concerned about the cost and the time it will take to implement the intervention. Whether or not such intervention will save them money is another factor they consider. Physicians want to be sure that the intervention will do what it sets out to do, that is reduce post surgical complications. They sometimes question the applicability of findings wondering if the population used in the studies to arrive at these interventions is similar to their patient population. Other questions to be taken into consideration include: Is the intervention feasible? Will it save money? Will it reduce errors and surgical complications? Will it be easier to administer or minitor? Will it cost more money to carry out?
VI. OPTIONS
a. Do Nothing
Doing nothing or sticking with the status quo would meet no political barrier and will cost nothing to implement. The inherent flaw of a policy decision to do nothing relies on the notion that “if it is not broken, doesn’t fix it.” But healthcare is broken; costs have gone up and complications are destroying lives and adding to the cost. Doing nothing is not going to change the situation; all stakeholders agree things need to change and something must be done.
b. Surgical Safety Checklist
The World Health Organization (WHO) launched the Safe Surgery Saves Lives campaign in January 2007 to improve consistency of surgical care and adherence to safety practices. As part of the campaign, the Surgical Safety Checklist was created through an international consultative process. It is a two-minute tool, much like the checklist a pilot uses before takeoff, and is designed to help operating room staff improve teamwork and ensure the consistent use of safety processes. It consists of a series of checks that occur before the delivery of anesthesia, before any incision is made in the skin, and before the patient leaves the operating room. These represent safety checks confirming that appropriate antibiotics have been given to prevent infection, the necessary equipment is available and no members of the team have any unaddressed questions or concerns before proceeding with the operation.[5] It is worth mentioning that the checklist is not intended to be comprehensive. Contrary to a wrong notion that the WHO involvement with the checklist means that it is not relevant to hospitals in the US, additions and modifications to fit local practice are encouraged[6] and that is what many hospitals across the globe have done with it.
In a pilot study of systematic implementation of the checklist, conducted by Marcus Semel and co, its use markedly decreased complications for patients undergoing non-cardiac surgery in eight diverse international hospitals with one site was in the United States. Among these four sites, there was a 30 percent reduction in major complications after the introduction of the checklist. That study and a previous one on the use of the checklist demonstrated that its adoption is a cost saving quality improvement tool.[7]
c. Education and Increased Awareness
In its simplest form, the surgical safety checklist begins right before incision and ends as the patient leaves the operating room. That begs the question of what happens before the patient comes into the operating room and days after the surgery. Just by itself as a standalone tool, the checklist is not adequate in addressing all of the reasons post operative complications do occur. Education and increased awareness can decrease preoperative errors. However, even with a carefully designed policy in place, an error-free environment was not achieved. Therefore, monitoring and system analysis should be performed on a continuing basis.[8] Some of the increased awareness and education programs are in the form of collaborative among hospitals and doctors like the Florida Surgical Care Initiative (FSCI), the Surgical Care Improvement Project (SCIP) or the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). In Michigan, 33 hospitals participating in a NSQIP collaborative saved more than $50 million/year from reduced complications.[9]
d. System Redesign
System redesign including culture change – A complete system redesign will set the stage for any education, or intervention that will be implemented. The current system, culture and process somehow inhibit those things that the checklist, for example is trying to address. To effectively carry out any intervention that will address the problem, a system redesign is necessary. According to the Institute of Healthcare Quality Improvement website, effective surgical infection prevention and harm reduction require redesigning systems with safety in mind. Based on what they called a fundamental law of improvement, they argue “every system is perfectly designed to achieve exactly the results it gets. In order to attain a new level of performance in safety, there must be a new system. This applies to all forms of performance — such as selection, timing, and duration of antimicrobial prophylaxis; thermoregulation; oxygen tension; glucose control; hair removal and other basic prevention strategies.”[10]
e. Education, increased awareness and Checklist
Education and Increased Awareness alone is not enough. You will need a tool like the checklist as part of the education and awareness program. Education and awareness covers all including patients & families, physicians, and other hospital staff. Combining Options one and two or when implemented together will require more money and take longer to implement, but it will address the problem in a long term as it deals with issues and people both inside and outside the operating room.
VII. COMPARISON OF OPTIONS
In the grid below, the chosen options are rated against each other based on the following criteria: feasibility, implementation cost, cost savings, rate of complications reduction, and administration. To asses each option, I use a numeric ranking system giving each factor a rating on a scale of one to five (five being a high score—one a low score,) as follows: Feasibility: a score of 5 means highly feasible—a score of 1 means low feasibility. Cost: lower potential cost of implementation 5- high potential cost of implementation 1. Cost savings: a score of 5 means higher potential to reduce cost, lower cost saving potential is 1. Complications: higher potential to reduce complications is 5, lower potential to reduce complication 1. Administration: higher administrative ease gets a ranking of 5 and low administrative ease 1.
|
SUMMARY OF RESULTS |
|||||
|
Criteria |
Do Nothing |
Checklist |
Education |
Redesign |
Checklist+Edu |
|
Feasibility |
2 |
5 |
4 |
1 |
3 |
|
Cost |
1 |
3 |
4 |
1 |
3 |
|
Cost Savings |
1 |
2 |
3 |
4 |
5 |
|
Complications |
1 |
2 |
3 |
4 |
5 |
|
Administration |
5 |
4 |
3 |
1 |
2 |
|
TOTAL |
10 |
16 |
17 |
12 |
18 |
VIII. RECOMMENDATION
A quantitative summary of the results shows combining the use of the surgical safety checklist in conjunction with education and increased awareness at this time receives the highest ranking of the five options. This score, however is very close to education on one hand and the use of the checklist on the right, so depending on the hospitals “feel” for the cost of implementation, the associated cost savings and their own set of values regarding the issue and the stakeholders involved, combining options Two and Five may be a viable alternative.
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