Surgical Services Improvement Plan (SSIP) Task Force. Dramatic effect of improved documentation on surgical mortality index

Background: In 2007 our hospital began submitting data to the National Surgery Quality Improvement Program (NSQIP). When the first report was available it demonstrated that our General and Vascular Surgery groups had a mortality index statistically greater than one.

Objective: In January 2008, a Surgical Services Improvement Plan Task Force (SSIPTF)was created under the auspices of the Chairman of Surgery with the charge of reducing surgical mortality.

Methods: The SSIPTF consisted of 8 groups focused on the following: 1) Documentation, 2) Preoperative optimization , 3) Communication, 4) SCIP Core Measures, 5) Intraoperative processes, 6) Surgery critical care, 7) Postoperative processes, 8) Discharge processes and complications developing post discharge. Each team was led by a surgeon chair and facilitated by Quality Improvement Coordinators, Six Sigma Black Belts and Green Belts.  Teams met every two weeks for 1 hour for the last 20 months and were comprised of multidisciplinary members including physicians, nurses and other care providers, informatics’ specialists, and administrative personnel.

Results: Early improvements were accomplished with documentation: for example, functional status: 45% to 92%, smoking pack years: 68% to 89% (P<0.05). Recent improvements (last 6-8 months) include a pilot screening program for nasal MRSA, creation of a preoperative video about mobility, incentive spirometry and pain control, design and piloting of an OR passport, improved VTE prophylaxis (85% to 95%, P<0.05), improved antibiotic redosing (20% to 90%, P<0.05), improved ICU mobility (14% to 85%, P<0.05), decreased hospital length of stay for ICU patients in mobility campaign (17.2 to 12.4, P<0.05), improved surgical floor mobility (80% to 100%). NSQIP data after the first year of the SSIP demonstrated that the surgical mortality index had decreased from an initial value of 1.21 down to 0.86 (p<0.05). This was associated with a dramatic increase in expected mortality (2.33 to 3.38) and no significant change in observed mortality (2.81 to 2.89). Notably in that same time frame our morbidity (surgical site infection, postoperative pneumonia) did not change significantly. This was not surprising given that many clinical interventions were not implemented until the end of the first year and were initially piloted on one unit or clinic.

Conclusions: Our NSQIP surgical mortality index improved dramatically in association with improved documentation. As the other process improvements described are implemented more broadly, we anticipate reduced infectious complications and observed mortality.