Quality Improvement Program A First At Danbury Hospital

DANBURY — Danbury Hospital is among growing group of medical institutions nationwide taking part in rigorous reviews of surgical cases that offer consumers and payers another tool for qualifying a preferred health care providers.

Danbury Hospital’s participation in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) underscores a commitment to patient safety and clinical excellence, according to Pierre Saldinger, MD, FACS, chairman of the Department of Surgery at Danbury Hospital.

“The data management system compiled by the American College of Surgeons [ACS] enables us to continuously monitor and improve the quality of surgical care. It’s a powerful tool that allows for continuous quality performance improvement,” said Dr. Saldinger, who serves as “surgeon champion” for the hospital’s NSQIP process.

“This is a collaborative, multidisciplinary effort that involves all parts of the organization,” said Anita Volpe, APRN-BC, with the Department of Performance Improvement at Danbury Hospital and “surgical clinical nurse reviewer” for NSQIP. “We have a team of surgeons, nurses, anesthesiologists, and other health care professionals committed to bringing the highest level of care to our patients.”

A longtime leader in the field, Danbury Hospital was the first in Connecticut to invest in NSQIP and is one of only four hospitals in the state currently participating in the program. Dr Saldinger and Ms Volpe recently spoke at the annual NSQIP national conference about the implementation of quality improvement activities at Danbury Hospital.

A benefit to both patients and hospitals, NSQIP significantly differs from other tools that compare hospitals in several ways:

*NSQIP is based on objective data selected to meet strict criteria set by the ACS, which conducts an annual data audit of participating hospitals to verify findings. “Consumers and payers can be confident they are viewing objective information,” said Dr Saldinger. “This is an attempt by the medical profession to improve performance in a regulated way.”

*The program offers fair comparisons of hospitals by providing risk-adjusted data that takes into account the severity of illness, including factors that could impact surgical outcomes, such as the presence of diabetes, cancer, or other conditions. “You can’t look at the data in isolation,” said Dr Saldinger. “One hospital may have a patient population that is much sicker.”

*The data is continuously entered into the national data base, making it readily available for review at any time. “We can compare our data with similar institutions nationwide in real time whenever the need arises,” said Ms Volpe.

NSQIP proved effective in the 1980s for the Department of Veterans Affairs, which wanted to improve the quality of its surgical care. Keenly aware of the advantages of having access to such data, the ACS began offering NSQIP to hospitals in the private sector in 2004.

The Institute of Medicine (IOM) has named NSQIP the “best in the nation” for measuring and reporting surgical quality and outcomes.

As the surgical clinical nurse reviewer, Ms Volpe reviews the entire surgical process — before, during, and after surgery — including a follow-up call to patients 30 days after surgery and a review of the surgeons’ medical records at their private office. “We look at more than 100 variables that can potentially impact mortality and morbidity [complication] rates,” she added.

At times, the NSQIP process can yield findings and identify trends that lead to action plans, such as reengineering the workflow process, fostering additional internal education, or developing clinical performance improvement initiatives, said Ms Volpe.

Danbury Hospital currently reviews all general, bariatric, and vascular surgery cases and plans to expand NSQIP to other surgical subspecialties in the future, said Dr Saldinger.

“This system allows for the constant review and evaluation of our systems so we can continue to provide patients with the finest surgical care possible,” he concluded.