5 Reasons Hospital ORs Score Low on Key Quality Measures

To maximize revenue under the CMS Hospital Value-Based Purchasing Program, hospital surgery departments need to score high on quality, outcome and patient satisfaction measures.

Dr. Thomas Blasco is medical director of the Illinois Sports Medicine and Orthopedic Surgery Center.The VBP Program tracks several measures from the Surgical Care Improvement Project. The program also incorporates patient satisfaction scores from the HCAHPS survey. Starting in fiscal year 2015, VBP will weave in several surgical complication measures, which are tracked by the American College of Surgeons National Surgical Quality Improvement Program.


Failing to score well on SCIP, HCAHPS and NSQIP measures could lead to significant reductions in Medicare payment. Yet most hospital ORs are not prepared to optimize their performance. Why?

Here are five reasons ORs fall short on key surgical quality metrics.

1. Physicians are left out. Some hospitals consider OR performance improvement to be a nursing initiative. This approach is ineffective because physicians are key drivers of surgical quality. Implementing the World Health Organization Surgical Safety Checklist, for example, requires strong commitment from both surgeons and anesthesiologists. Organizational silos make it impossible for nursing management alone to lead a checklist implementation. Surgical quality improvement requires true multidisciplinary leadership.

Many leading hospitals have improved quality measures significantly by establishing a surgical services executive committee to manage OR operations. An SSEC is a hospital-sponsored governance body that includes all OR stakeholders — surgeons, anesthesiologists, nursing and C-level administration. As a physician-led "board of directors" for surgical services, the SSEC is empowered to sponsor performance improvement initiatives and hold all stakeholders accountable for meeting operational expectations.

2. Standards lack teeth. Getting people to adopt new standards is not easy in healthcare. Unfortunately, the "soft touch" only goes so far. OR leaders need the power to enforce quality and safety expectations.

In my anesthesia group, for instance, physicians can receive substantial fines for repeated failure to abide by agreed-upon standards for antibiotic prophylaxis. Well-run ORs also hold surgeons accountable for meeting performance expectations. For example, effective department chairs personally intervene with surgeons who do not consistently participate in time-outs. Initially, the approach is supportive and encouraging. But ongoing noncompliance has consequences, including loss of a schedule block and, for the most serious problems, loss of hospital privileges.

This underscores the importance of physician leadership in the OR. Quality standards can have teeth only if they are established and enforced by physician peers.

3. Staff fumbles data collection. Hospitals that want to improve quality performance need to track performance data. The problem is that most ORs are poor at data collection and analysis. Lack of good data makes it impossible to guide improvement efforts. And if physicians begin to doubt the integrity of your data, you can expect strong pushback on any change initiatives.

First, realize that good data costs money. The OR must invest in the staff hours to collect data and the expertise to analyze it. Oversight is critical. Nurses must clearly understand it is absolutely essential to collect and input data accurately. Data also needs to drive action. OR leadership and front-line management should receive data reports on a weekly basis. Any reported performance shortfall should lead to an immediate intervention.

4. Changes are not hardwired. Committee work alone does not lead to quality improvement. To upgrade and maintain high performance, an OR needs to hardwire changes into the organization through new processes and persistent oversight.

One effective practice is to embed quality checks into physician billing sheets. Anesthesia billing sheets, for example, can include questions about key quality practices: Were antibiotics given? What type and dose? When were they started? Sheets should be audited periodically and peers should follow up on shortfalls. The system reinforces actions to establish habits.

Similar systems can be put in place for nurses. Checklists are an important tool. For example, a patient transfer checklist could include questions like: Has the antibiotic drip been started? Is the compression boot on the patient and operating? Incorporating these aids into nursing processes — and firmly insisting on compliance — will eventually turn standards into second nature.

5. Hospital leaders are MIA. The issue that underlies all the above problems is lack of leadership from hospital administration. Without strong executive sponsorship, organizational silos cannot be broken down, longstanding practices cannot be changed and new performance standards cannot be established.

To improve surgical quality and patient satisfaction, hospital leaders must communicate goals to all OR constituencies, empower front-line leaders and leadership teams (like the SSEC) to execute changes and hold all stakeholders accountable for progress. SCIP, HCAHPS and NSQIP scores will improve when hospital leadership clearly signals the intention to move forward and not move back.

Thomas Blasco, MD, MS, is a managing partner of Surgical Directions, a physician-led consulting firm that helps hospital ORs improve clinical outcomes, financial performance and patient and staff satisfaction. He is a practicing board-certified anesthesiologist/intensivist and currently serves as the medical director of the Illinois Sports Medicine and Orthopedic Surgery Center in Morton Grove.

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