Knowledge is Power
Knowledge is Power | Tennessee Surgical Quality Collaborative, TSQC, Dr. Joe Cofer, American College of Surgeons, National Surgical Quality Improvement Program, NSQIP, ACS, TNACS, Dr. Oscar Guillamondegui

Dr. Joe Cofer
TSQC Helps Participating Hospitals Improve Performance

It’s hard to fix what you don’t know is broken.

When three Tennessee hospitals — Erlanger in Chattanooga, Vanderbilt in Nashville, and St. Francis in Memphis — signed on to participate in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), their administrators and surgeons took the first steps in founding what has become a unique and extremely powerful quality improvement organization … the Tennessee Surgical Quality Collaborative (TSQC).

Prior to NSQIP, Joe Cofer, MD, FACS, chairman of TSQC’s Leadership Committee and president-elect for the Tennessee Chapter of the American College of Surgeons, said surgeons only had claims data and other non-standardized statistics available, making it difficult to act upon the information … or even trust it.

“Once you start showing surgeons data they believe in, they get better,” noted the professor of Surgery for the University of Tennessee College of Medicine – Chattanooga. “What makes NSQIP so powerful is it’s a standardized, validated method across all hospitals where you collect a statistically valid sample of 40 cases over eight days, collecting the same variables in all patients, and then you have 30-day outcomes.”

With this nationally-validated, risk-adjusted, outcomes-based approach, surgeons have a trust level that was previously absent. In turn, that has directly impacted quality. “If a surgeon sees their wound infection rate is unacceptably high, they strive to lower it,” Cofer pointed out.

In a landmark paper in the Annals of Surgery (Sept. 2009), Bruce Hall, MD, PhD, MBA, FACS, outlined how the ACS NSQIP data spanning three years from 2005-2007 was used to improve performance measures among participating hospitals. In the analysis, which included more than 100 hospitals across geographic regions of the United States, 66 percent improved risk-adjusted mortality, and 82 percent improved risk-adjusted complication rates.

Cofer, who is a general surgeon on staff at Erlanger, said Tennessee stakeholders very quickly recognized the importance of NSQIP data and the impact it could have on patients. Although Michigan was the first to create a statewide quality collaborative using NSQIP data, Tennessee was a very early adopter and had launched a program by 2008.

“We were the first collaboration to be formed between the hospitals and the surgeons and the payer … and that’s unique because historically those three have had competing interests,” Cofer explained. He added the partnership between the Tennessee Hospital Association, Tennessee Chapter of ACS, and BlueCross BlueShield of Tennessee Health Foundation was an affirmation that the three groups recognized “the primary interest should be always for the patient.”

He continued, “I don’t know any other collaboration that has that three-legged stool. We banded together to put patient outcomes and patient safety first.”

In Tennessee, the THA houses the infrastructure and acts as administrator of TSQC. BCBST Foundation has provided the funding mechanism to cover about half the cost of hospital participation, which runs about $100,000 to hire a full-time clinical abstractor and join NSQIP. At the facility level, each hospital has a designated surgeon champion to oversee the onsite program, review data and discuss outcomes measures with individual surgeons as warranted.

Reports, which can only be pulled by the surgeon champion, track data and outcomes for individual surgeons. Cofer noted, “I think that’s what Bruce Hall said in his paper … if you give surgeons data they can believe, they will improve their behavior, improve their performance.” He continued, “Surgeons are very competitive. They want to be the best … or at least competent … and they sure don’t want to be the worst.”

Earlier this year, an article in the Journal of the American College of Surgeons (JACS) underscored the reduced costs and improved outcomes among participants in TSQC comparing calendar year 2010 (period 2) to 2009 (period 1). Oscar Guillamondegui, MD, FACS, with the Department of Surgery at Vanderbilt University Medical Center served as lead author of the 2012 JACS article and principal investigator of a study looking at NSQIP data in 20 categories plus 30-day mortality rates across the 10-hospital collaborative.

Normalizing data to rates per 10,000, the research team found an 18.9 percent decrease from period 1 to period 2 in superficial surgical site infections, a 14.7 percent decrease in patients on the ventilator longer than 48 hours, a 60.5 percent decrease in graft/prosthesis/flap failure, a 25.1 percent decrease in acute renal failure and a 34.3 percent decrease in wound disruption. There was no statistically significant difference in mortality rates over the two years, but the number of deaths per 10,000 was slightly higher in period 2 compared to period 1 (237.6 vs. 232.3).

Not all the news was good. “We can’t just tout our successes and ignore our deficiencies,” noted Cofer, who participated in the study and the article. He added there were several areas that statistically worsened during the 2010 reporting cycle including a 34.9 percent increase in DVT/thrombophlebitis, a 23.1 percent increase in reported cases of pneumonia, and a 41.8 percent increase in urinary tract infections.

Ultimately, using the NSQIP ROI (return on investment) calculator, the 10 participating hospitals saved $4,476,515 in period 2 compared to period 1 through quality improvements. The three key areas where outcomes worsened resulted in an increased cost across the collaborative of $2,278,972. However, the net overall savings from avoiding complications came in at $2,197,543 for period 2.

Cofer added the $2 million in savings per 10,000 general and vascular surgery cases grabbed a lot of media attention. However, he continued, “We should really be celebrating the dramatic improvement in care overall.”

The number of hospital participants in TSQC has recently almost doubled thanks to an additional BCBST Foundation grant. “As of January of this year, we’ve expanded to 20 hospitals,” said Cofer, who added the original BCBST grant concluded at the end of 2011 but a new grant launched in January 2012 to fund the nine new hospitals for three years and provide a decreasing percentage of funding to the original 10 participants.

Even if hospitals are called upon to self-fund TSQC participation at some point in the future, Cofer said it should be a ‘no brainer’ to allocate money to a program that has proven to greatly benefit both patients and a hospital’s bottom line. The ultimate value, he continued, is in not only being able to fix what is broken but also in knowing just how broken an area is in comparison to others.

“All of us are good in some things and not good in some things. We all have areas that need improvement,” he said. “As a collaborative, what we’re trying to do is identify outliers who have the best rates and find out what they are doing so well. We’re trying to dissect out best practices and export those best practices back to the collaborative.”

Cofer concluded, “It’s a constant battle, but that’s what having data does … it helps you identify your strengths and weaknesses.”





TSQC Participants

Experienced NSQIP Sites

Baptist Memorial (Memphis)

Cookeville Regional Medical Center (Cookeville)

Erlanger Medical Center (Chattanooga)

Jackson Madison County General Hospital (Jackson)

Johnson City Medical Center (Johnson City)

Methodist University (Memphis)

Parkwest Medical Center (Knoxville)

St. Francis Hospital (Memphis)

University of Tennessee Medical Center (Knoxville)

Vanderbilt University Hospital (Nashville)


New for 2012

Baptist Hospital (Nashville)

Claiborne County Hospital (Tazewell)

Cumberland Medical Center (Crossville)

Ft. Sanders Regional Medical Center (Knoxville)

Henry County Medical Center (Paris)

Maury Regional Medical Center (Columbia)

Memorial Health Care System (Chattanooga)

NorthCrest Medical Center (Springfield)

Saint Thomas Hospital (Nashville)

Wellmont Bristol Regional Medical Center (Bristol)   



Mark Your Calendar

Tennessee Chapter of the American College of Surgeons 2012 Annual Meeting

August 3-5, 2012

The Chattanoogan • Chattanooga, Tenn.

For Meeting & Registration Information:

Friday, Aug. 3: The opening day, which will be devoted to quality improvement, has been designated by the American College of Surgeons (ACS) as one of the national organization’s “Inspiring Quality” forums. The day will include panel discussions with Tennessee Surgical Quality Collaboration (TSQC) participants and national healthcare policymakers. Other highlights include a presentation by Joe Cofer, MD, FACS, regarding the lessons learned from the TSQC, a surgeon’s view of quality improvement, the influence of culture on quality improvement, and information on the state’s Colorectal/SSI Reduction Project. The afternoon culminates in an ACS update by David Hoyt, MD, FACS, executive director of the American College of Surgeons.

Saturday, Aug. 4: After a session on surgical simulation in Tennessee, attendees will break into two ancillary groups focused on cancer and trauma. In the afternoon, an expert panel will be “on the hot seat” as they respond to difficult surgical questions submitted by attendees.

Sunday, Aug. 5: The day begins with a presentation by a Tennessee Medical Association expert on Tennessee’s prescription drug abuse crisis. After splitting into two groups for basic science and clinical science presentations, the weekend culminates in the annual business meeting and installation of 2012-13 officers — President: Oscar Guillamondegui, MD, FACS, Vanderbilt; President-Elect: Joe Cofer, MD, FACS, Erlanger; Immediate Past President: Tiffany Bee, MD, FACS, University of Tennessee Health Science Center.