Are We Supporting Surgical Quality Improvement in Training and Beyond? A Qualitative Study of Surgical Trainees and Practicing Surgeons.

BACKGROUND: We conducted a qualitative study to describe surgeon and surgical trainee perspectives of quality improvement (QI) in training and practice to elucidate how surgeons and trainees interact with barriers and leverage facilitators to learn and conduct QI. STUDY DESIGN: Surgeons and surgical trainees of the American College of Surgeons were recruited via email and snowball sampling to participate in focus groups. Eligible individuals were English speaking surgical trainees or practicing surgeons. We developed a semi-structured focus group protocol to explore barriers and facilitators of quality training and improvement. An inductive thematic approach was used to identify actionable items. RESULTS: Thirty-two surgical trainees and surgeons participated in six focus groups. 28% of participants were trainees (8 residents, 1 fellow) and 72% were practicing surgeons, representing practice settings in university, community, and Veterans Affairs hospitals in urban and suburban regions. Thematic analysis revealed the central theme among trainees was that they lacked necessary support to effectively learn and conduct QI. Dominant sub-themes included lack of formal education, insufficient time, inconsistent mentorship, and maximizing self-sufficiency to promotes success. The central theme among surgeons was that effective QI initiatives require adequate resources and institutional support; however, surgeons in this study were ultimately constrained by institutional limitations. Sub-themes included difficulties in data acquisition and interpretation, financial limitations, workforce and staffing challenges, misaligned stakeholder priorities, and institutional culture. CONCLUSION: This qualitative evaluation further details gaps in QI demonstrated by previous quantitative studies. There is an opportunity to address these gaps with dedicated QI training and mentorship for surgical trainees and by creating a supportive environment with ample resources for surgeons.

How Well Is Surgical Improvement Being Conducted? Evaluation of 50 Local Surgery-Related Improvement Efforts.

BACKGROUND: Delivering high-quality care is paramount; however, evaluations show mixed results. Studies assessing improvement efforts in nonsurgical disciplines show suboptimal conduct, yet little is known about how well improvement efforts in surgery are conducted. This study evaluates local surgical improvement efforts to determine whether opportunities exist to improve their conduct. STUDY DESIGN: Fifty consecutive improvement efforts were collected from hospitals participating in 1 of 5 American College of Surgeons Quality Accreditation/Verification Programs. Conduct of these efforts was evaluated using a quality framework (with 39 criteria grouped into 8 components). Descriptive, paired, and 1-way ANOVA analyses were undertaken. RESULTS: The mean percentage of 39 criteria fulfilled for the 50 improvement efforts was 36% (range 0% to 72%). Individual criterion scores ranged from 0% to 82%. The 2 highest scoring criteria were improvement planning and problem documentation; the 2 lowest scoring were value assessments and stakeholder value perspective. The highest scoring framework component addressed End-of-Project Decision-Making (47%); the lowest was Cost Evaluation (3%). Twenty-four percent of 50 improvement efforts reported full achievement of project goals, 32% reported partial achievement, and 44% reported no achievement. Higher scores were associated with projects having full/partial achievement of stated project goals vs projects not achieving project goals (p < 0.05). Higher scores were not associated with hospital characteristics (eg bed size, teaching status) or improvement characteristics (eg improvement strategy). CONCLUSIONS: Evaluation of local surgical improvement efforts shows opportunities for improvement. Better-conducted improvement efforts were associated with more effective improvement. To support better surgical quality of care, improvement efforts need to improve.

Reconceptualizing poststroke activity level using the Frenchay Activities Index.

Modifications of the Frenchay Activities Index were implemented in a study of postacute stroke rehabilitation outcomes. These modifications incorporated the prestroke activity levels and postrehabilitation goals and assessments of activity importance of 136 persons with stroke who received services in either a single modality or comprehensive outpatient rehabilitation setting. Prestroke activity levels were assessed retrospectively at admission to postacute rehabilitation, and current activity levels were assessed at discharge and 3 months post discharge. Prestroke activity levels were used to determine postrehabilitation goal attainment. Results showed that activities for which goals were less likely to be attained were more strenuous in nature, and activities for which goals were more likely to be attained were more sedentary in nature. The importance persons placed on specific activities was used to tailor the estimates of overall activity levels to reflect their importance to each person. Results showed that adjusting for importance decreased the estimate of prestroke activity level but had little effect on poststroke activity level. Incorporation of these modifications represents a reconceptualization of poststroke activity levels that clinicians can use to guide their selection of postacute rehabilitation therapy goals.

Evaluation of initial participation in public reporting of American College of Surgeons NSQIP surgical outcomes on Medicare's Hospital Compare website.

BACKGROUND: In October 2012, The Centers for Medicare and Medicaid Services (CMS) began publicly reporting American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) surgical outcomes on its public reporting website, Hospital Compare. Participation in this CMS-NSQIP initiative is voluntary. Our objective was to compare CMS-NSQIP participating hospitals with ACS NSQIP hospitals that elected not to participate. STUDY DESIGN: Hospital Compare and American Hospital Association Annual Survey data were merged to compare CMS-NSQIP participants with nonparticipants. Regression models were developed to assess predictors of participation and to assess if hospitals differed on 32 process, 10 patient experience (Hospital Consumer Assessment of HealthCare Providers and Systems [HCAHPS]), and 16 outcomes (Hospital Compare and Agency for Healthcare Research Quality) measures. Additionally, performance on 2 waves of publicly reported ACS NSQIP surgical outcomes measures was compared. RESULTS: Of the 452 ACS NSQIP hospitals, 80 (18%) participated in CMS-NSQIP public reporting. Participating hospitals had more beds, admissions, operations, and were more often accredited (Commission on Cancer and the Council of Teaching Hospitals [COTH] [p < 0.05]). Only COTH membership remained significant in adjusted analyses (odds ratio 2.45, 95% CI 1.12 to 5.35). Hospital performance on process, HCAHPS, and outcomes measures were not associated with CMS-NSQIP participation for 54 of 58 measures examined. Hospitals with "better-than-average" performance were more likely to publicly report the Elderly Surgery measure (p < 0.05). In wave 2, an increased proportion of new participants reported "worse-than-average" outcomes. CONCLUSIONS: There were few measurable differences between CMS-NSQIP participating and nonparticipating hospitals. The decision to voluntarily publicly report may be related to the hospital's culture of quality improvement and transparency.