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SCOAP Community Speaks Up: Tracking Length of Stay

Colleagues at Valley General Hospital in Renton asked “Why is SCOAP starting to ask questions about time of admission and discharge?” and others have asked similar questions what SCOAP is trying to get at when it focuses on length of stay.

Questions like these are a great opportunity to make sure all SCOAP surgeons are on the same page about how this grassroots collaborative picks metrics and why certain data points are being collected. Beginning January 2010, SCOAP added admission and discharge times for all cases, and for non-elective surgery (like appendectomies and some colorectal procedures) the time of arrival at the Emergency Room as well. Finding and abstracting times in a consistent manner has been a surprising challenge, prompting some of the above questions, but this metric is important. For non-elective surgery like appendectomies, the goal of time of arrival is tracking the time between first contact with the hospital and operation.  Adding times may help address a question that we’re often asked-can appendectomy be delayed until the morning without hurting patients (and its corollary-is it the standard of care to always have an in-hospital surgeon or night-time appendectomy by the on-call surgery for patients who come in at night). This is becoming increasingly relevant for all non-elective procedures where SCOAP surgeons are trying to reduce morbidity.

Calculating time to OR-Is SCOAP suggesting all appendectomy cases that come in at night be done in the middle of the night?

As you can see in the figures in this newsletter, the rates of perforated appendicitis in SCOAP varies considerably across hospitals.  Why is there so much variability in rates of perforation among our hospitals?  What can surgeons and ER docs do about higher rates of perforation?  Pre-hospital delays to first contact or misdiagnoses in the ER may also be linked with higher rates of perforation.  One way we can assess the frequency of modifiable, pre-hospital delay is by looking at the proportion of patients with perforation seen in the ER within a week prior to their appendectomy visit (Figure 2 in this month’s newsletter).  As you can see by the figure, at some hospitals there are very high rates of “missed opportunity” for an earlier diagnosis. There was a wide range (2% to 75%) of perforated patients who were in the system in the week prior.  Perhaps the main reason for getting ER evaluation time is that there has been a long held belief that delaying an appendectomy once the patient is admitted to the hospital will cause an increase in the rate of perforations-that’s something SCOAP is able to address. SCOAP surgeons are working on the length of time from first contact to imaging, and imaging to appendectomy to determine how much of this perforation rate is related to in-hospital delays.  Time from first contact to operation may be one of the only true modifiable risk factors for perforation.

It’s not all about in-hospital delay.  Patients with perforation often have delayed treatment and have limited access to healthcare -often linked to socioeconomic status. Several studies have looked at the time between symptom onset in appendicitis and surgery. In a retrospective review of 1081 adult patients who underwent appendectomy for acute appendicitis between 1998 and 2004, Detillo et al[1] found that the odds of having a perforation were 13 times higher when the total interval exceeded 71 hours compared with a total interval below 12 hours. Patient delay in presenting to the Emergency Room was more related to perforation than in-hospital delays.  Since our ability as surgeons to minimize delay in presentation to the ER is limited, the authors concluded that every effort should be made to expedite the evaluation and operation of admitted patients with suspected appendicitis. There are some that even believe that perforated appendicitis represents a different disease process that earlier intervention might not impact.  Evidence for this is inferred by a study of the National Hospital Discharge Survey 1970-1994[2] suggesting that perforated appendicitis has been “non-responsive” to trends in laparoscopy and advanced imaging.   

Information about the role of in-hospital delay has implications for staffing of “on-call” surgical services (very relevant for areas where surgeon supply is limited) and may help hospitals better understand the impact of in-house surgeons, another important emerging trend.  The same information may be relevant for other areas of non-elective surgery and will be the focus of SCOAP evaluations in the future.

Calculating Length of Stay (LOS)- Are we targeting LOS just for fiscal reasons?

Prolonged LOS after elective surgery is increases the risk of nosocomial infections like MRSA, VRE and C. Dificil colitis[3].  The Centers for Disease Control and Prevention (CDC) estimates that about 2 million people contract hospital-acquired infections each year, with nearly 90,000 fatalities. Every hour in the hospital increases a patient’s risk of nosocomial infection. The July 2010 issue of General Surgery News featured a study presented by Todd R. Vogel, MD, MPH, (Assistant professor of surgery, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, N.J. and a former contributor to SCOAP) at the 2010 annual meeting of the Surgical Infection Society. In this study focused on adults older than 40 years of age who underwent elective CABG, colon resection and lung resection, investigators identified more than 163,000 procedures that met study criteria and found that patients had markedly higher rates of all nosocomial infections if they had an in-hospital delay in surgery of just one day. With each day, risk for infection grew, particularly urinary tract infection and pneumonia. This is reason enough to work on decreasing our patient’s exposure to hospital pathogens by reducing length of stay.  

Prolonged length of stay also increases the cost of care, may limit bed availability, and decreases hospital profitability.  We need to continually make the business case for quality improvement in SCOAP. Given the costs of participation, the support and involvement of senior hospital leaders is crucial and that requires a sound business case. Data demonstrating both reduced complications and increased profitability through decreased LOS provides the justification needed to fund staff SCOAP participation.   

Several SCOAP initiatives have been focused on reducing length of stay and we’ve achieved remarkable success in shortening LOS in elective surgery over the last 5 years.  SCOAP’s previous unit of time measurement (using dates rather than hours) may have been too crude to identify the small changes that when used together may have impact measured in days.  For that reason as well we have added time of discharge to the dataset. 

 How can we be sure that emphasis on reducing length of stay does not result in unintended consequences? If patients are rushed out of the hospital, won’t there be more readmissions?

SCOAP’s primary goal is to make surgical care safer, higher quality and as efficient as possible. We include a set of post-discharge follow-up questions so that hospitals also benchmark on readmissions within thirty days and any complications that occurred after discharge.  These outcome data will answer the question about whether “Enhanced Recovery” or “Fast Track Protocols” aimed at reducing LOS are helping or hurting.  Hospitals can use their SCOAP data to measure the success of system changes and ensure that clinical quality improvement stays front and center.  As pressure increases from payers to pay for a global episode of care SCOAP surgeons are hoping to be positioned to make sure we are doing the right things for our patients and not just shifting care to the outpatient environment.  More news to follow as these data are gathered from all  the hospitals across the network.

Thanks for the great questions and all you do to make SCOAP a success! 


[1] Ditillo MF, Dziura JD, Rabinovici R. Is it safe to delay appendectomy in adults with acute appendicitis? Ann Surg 2006;244(5):656–68.

[2]  Livingston EH, et al. Disconnect between incidence of nonperforated and perforated appendicitis: implications for pathophysiology and management. Ann Surg. 2007;245:886–92. doi: 10.1097/01.sla.0000256391.05233.aa.

 [3] Siegel JD, Rhinehart E, Jackson M, Chiarello L, Healthcare Infection Control Practices Advisory Committee. Management of multidrug-resistant organisms in healthcare settings. Atlanta (GA): Centers for Disease Control and Prevention; 2006


SCOAP Community Speaks Up: Advanced Pain Control

Surgeons at Sacred Heart in Spokane have asked “Is pain control getting in the way of recovery?”

Over the last five years, SCOAP has collected data to signal hospitals about their use of advanced pain control. One frequent question our patients ask when preparing for an elective surgery is, “How much pain will I have?” SCOAP recognizes that effective pain control requires giving patients active participation and control of their pain management and is the standard of care.  Evidence suggests that effective pain control reduces complications, decreases length of stay and improves patient comfort, satisfaction and outcome.  Effective pain control has included the element of advanced pain management, defined as a pain control method that is patient-controlled either through Patient Controlled Analgesia (PCA) or Patient Controlled Epidural Analgesia (PCEA).  SCOAP measures and benchmarks whether bariatric and colorectal patients receive advanced pain control (Patient-Controlled Analgesia or Epidural) following their operation.

Which method is preferable?
A meta-analysis[1] of 100 RCTs of randomized patients (abdominal surgery-36%, thoracic-24%, and lower extremity-12%) who received postoperative analgesia-either epidural analgesia or parenteral opioids found that for abdominal surgery, all epidural regimens were better postoperative analgesia than parenteral opioids.  Another meta-analysis of sixteen studies of only patients having colorectal surgery determined that although systemic opioids are effective for pain, they delay recovery of colonic mobility and prolong postoperative ileus.[2]

Do epidurals delay or help recovery?
Emerging evidence from multimodal “enhanced” recovery programs[3] – implementation of a perioperative patient care paradigm that reduces the time to discharge home and resumption of activities of daily living after surgical procedures – indicates that pain control, while an important aspect of patient care, needs to be considered not as a separate intervention but as one crucial component in a bundled care path.  

A key component of enhanced recovery programs is early ambulation. This is made possible by eliminating barriers such as the “two point restraint” of the Foley catheter and PCA, and the “three point restraint” when a routine NG tube is also in place.  In a recent SCOAP data review comparing length of stay (LOS) data from Q3 2008 through Q4 2009, hospitals in Washington State with lower LOS provided PCA’s to 90% of elective open colon/rectal patients and epidurals to 10%.   Hospitals with higher LOS used PCAs for 83% of these patients and epidurals for 28%.  In exploring this interesting finding it became apparent that we needed to get more information to better understand the reasons for prolonged length of stay.

As of January 2010 we are measuring how soon the patient is able to ambulate through the measure of the “voiding epidural” which is calculated using the date the patient’s Foley catheter is removed in patients who have epidurals. The recently issued Q1 2010 SCOAP report reflects these changes with new metrics. As more hospitals develop enhanced recovery protocols with multi-modal approaches, postoperative pain management is addressed in increasingly detailed and specific ways and SCOAP is evolving in response.

Is there evidence for the “voiding” epidural approach to pain control?
In a randomized trial of 54 patients[4] undergoing partial colectomy surgery, thoracic epidural analgesia (TEA) with bupivacaine and morphine inserted at the T8-T10 vertebral interspace was shown to provide the best balance of analgesia and side effects while accelerating postoperative recovery of gastrointestinal function and time to fulfillment of discharge criteria after colon surgery in relatively healthy patients within the context of a multimodal recovery program. The so-called “Walking/Voiding” epidurals provide pain relief and also allow patients to be up and out of bed sooner and more comfortably.  In another recent study,[5] sixty patients undergoing thoracic or thoraco-abdominal surgery were studied prospectively. Patients were randomly assigned   to receive either TEA or patient-controlled  i.v. opiate analgesia (PCA) after their operation. Visual analogue pain and sedation scores were recorded for the period of the study. The authors concluded that epidural analgesia with local anesthetic and opioid improved quality of life and delivered better analgesia compared with PCA.

There is also evidence that the practice of keeping a urinary catheter in place postoperatively when a patient has a thoracic epidural to avoid urinary retention may not be necessary.  A recent randomized study[6] of patients scheduled for thoracic and abdominal surgery and receiving continuous thoracic epidural analgesia found that leaving the bladder catheter as long as the epidural analgesia is maintained results in a higher incidence of UTI and prolonged hospital stay. Removal of the bladder catheter on the morning after surgery does not lead to higher rate of catheterizations.

Surgeons at Southwest asked “Are there special considerations for pain control with bariatric patients? We are concerned about using PCAs for these patients.”
For patients with clinically severe obesity (BMI≥35 kg/m2) who present for bariatric surgery, the incidence of obstructive sleep apnea (OSA) ranges from 71% to 77%. Postoperatively, patients with OSA present the anesthesiologist, surgeon, and nursing staff with a difficult situation. Although diminution of pain is the goal of every caregiver, the use of narcotics is especially dangerous in patients with OSA. After the use of any general anesthetic, the patient with OSA will exhibit a propensity for rapid eye movement (REM) sleep during the first several days after surgery.  In the patient with OSA, the genioglossus muscle is virtually paralyzed during REM sleep, allowing the tongue to fall posteriorly to the retroglossal space. Normally, such patients would arouse and terminate REM sleep, but this reflex is diminished with the administration of narcotics or sedatives.

For patients with severe pain and the need for opiates, the risk of over-sedation and airway compromise is clearly increased. In patients with OSA, respiratory depression culminating in respiratory arrest has been reported after an intravenous “push” of opioid analgesics, an epidural infusion of opioid analgesia  and with the use of patient-controlled opioid analgesia. Proper patient positioning (e.g., HOB to 30°), the administration of CPAP, nursing monitoring and limited use of narcotic analgesics have been recommended to address these risks.  Some hospitals admit these patients to the ICU for a brief period to provide more nursing support and assessment of the patient’s needs. Nonsteroidal anti-inflammatory drugs (NSAIDs) may be used as an adjunct for postoperative pain control as the use of NSAIDs can decrease opioid use by 20% to 35%.[7]  There is no literature that indicates a clear contraindication to use of a PCA or PCEA.

What about laparoscopic surgery?
Pain control following laparoscopic surgery is related to the size of incisions. Some colorectal surgeries that are hand-assisted may have a significant incision.  A retrospective analysis[8] of hospital records was performed for 16 patients undergoing laparoscopic colorectal surgery. Thoracic epidural in this study offered optimal analgesia and quality of care.  Other considerations for pain control in laparoscopic colorectal surgery have focused on decreasing length of stay. A randomized clinical trial[9] of patients undergoing segmental laparoscopic colectomy compared PCA vs. TEA and found that TEA significantly improved early analgesia following laparoscopic colectomy but did not affect the length of hospital stay.

What are best-performing SCOAP hospitals doing to ensure patients have optimal pain control and recovery?
SCOAP hospitals that are successfully addressing postoperative pain control have developed strategies and guidelines to standardize all aspects of care during the entire perioperative period.   They have formed teams that include key players such as anesthesia staff, nursing staff and other clinicians to address ongoing quality improvement activities and are providing training and coaching to staff so they understand and are supportive of the organization’s approach to postoperative recovery,  and the need to provide effective pain management that optimizes patient outcome.  They also use SCOAP data to figure out whether or not strategies like epidurals are helping or restricting their patients.  Evidence suggests that patients with open bariatric or colorectal operations should receive a thoracic epidural that is properly positioned to allow ambulation and voiding, and that pain control be considered as part of the multi-modal approach to surgical recovery. Patients with large laparoscopic incisions may also benefit from thoracic epidurals. Bariatric patients with OSA require careful monitoring and limited use of narcotic analgesics.  Only by tracking on the effectiveness and impact of advanced pain control will we balance the benefits and drawbacks of this powerful technology.

Thanks for all you do as a part of SCOAP.

[1] Block BM, Liu SS, Rowlingson AJ, Cowan AR, Cowan JA Jr, Wu CL. Efficacy of postoperative epidural analgesia: a meta-analysis. JAMA. 2003;290(18):2455-2463

[2] Marret E, Remy C, Bonnet F, Postoperative Pain Forum Group. Meta-analysis of epidural analgesia vs. parenteral opioid analgesia after colorectal surgery. Br J Surg. 2007; 94(6):665-673.

[3] Lassen K, Soop M, Nygren J, Cox PBW, Hendry PO, Spies C et al.  Consensus review of optimal perioperative care in colorectal surgery. Arch Surg 2009; 144: 961–969.

[4] Liu SS, Carpenter RL, Mackey DC, Thirlby RC, Rupp SM, Shine TS, Feinglass NG, Metzger PP, Fulmer JT, Smith SL: Effects of perioperative analgesic technique on rate of recovery after colon surgery. Anesthesiology 1995; 83:757-65

[5] Ali, M, Winter DC , Hanly AM, O’Hagan C,  Keaveny J, Broe P.  Prospective, randomized, controlled trial of thoracic epidural or patient-controlled opiate analgesia on perioperative quality of life. Br. J. Anaesth. 2010 104: 292-297.

[6] Zaouter C, Kaneva P, Carli F. Less Urinary Tract Infection by Earlier Removal of Bladder Catheter in Surgical Patients Receiving Thoracic Epidural Analgesia Regional Anesthesia & Pain Medicine: November/December 2009 – Volume 34 – Issue 6 – pp 542-548

[7] Bell R, Rosenbaum S. Postoperative considerations for patients with obesity and sleep apnea. Anesthesiol Clin N Am 23 (2005), pp. 493–500.

[8] Dennis, RJ, Mills, P. Thoracic Epidural versus Morphine Patient Controlled Analgesia After Laparoscopic Colectomy World Journal of Laparoscopic Surgery, September-December 2008.

[9] Senagore AJ, Delaney CP, Mekhail N, Dugan A, Fazio VW. Randomised clinical trial comparing epidural anaesthesia and patient controlled analgesia after laparoscopic segmental colectomy. Br.J.Surg 2003; 90: 1195–9.

SCOAP Making a Difference: Enhancing Recovery of GI Function

At the SCOAP Annual Retreat on May 4, 2010, Dr. Anthony Senagore, Professor of Surgery at Michigan State University, spoke about several controversial issues around avoiding post-operative ileus, including ways to limit ileus by avoiding prolonged PCA use, prudent management of epidural use, and increased use of opiod antagonists like Entereg. 

SCOAP is addressing these issues in the following ways:   
1) Tracking on prolonged use of PCA – Beginning in Q1 2011, we will track the number of days with PCA.
2) Tracking on the adequacy of epidurals to allow patients to void – Beginning in Q1 2010, we will track foley catheter use beyond postoperative day 2 among patients receiving epidurals.  This is one way to asses if an epidural is high enough to allow mobility.
3) Increased opioid use – We continue to track the use of Entereg, and be part of the emerging evidence that determines if Entereg is making a difference in the community at large.  

Dr. Senagore’s slides can be viewed here.  

For more information on the retreat, visit the Retreats page on the SCOAP website.

SCOAP Community Speaks Up: Use of Nasogatric Tubes

SCOAP is targeting a reduction in the use of nasogastric tubes (NGT) to accelerate GI recovery.  Some of our colleagues favor the routine use of NGTs because they were taught it reduces complications linked to GI distention-hernia, wound dehiscence and nausea/vomiting. 

 This prompted surgeons in Port Angeles to ask “Does the routine use of NGTs decrease complications?

SCOAP measures whether or not NGTs are  used upon leaving the operating room (excluding patients who are mechanically ventilated) and when the NGT is removed.  At hospitals that have shorter length of stay routine NGTs are rarely used.  There is a growing body of evidence that supports avoiding routine NGT use. One meta-analysis[i] of 28 published studies examined the efficacy of prophylactic NGT use after abdominal surgery.   A broad range of abdominal surgery was covered in these papers; there were seven on colorectal surgery, seven on gastroduodenal surgery, two each on biliary and gynecological surgery, one each on vascular and emergency trauma surgery, and seven that included all facets of abdominal surgery. The included publications described 4195 participants, 2108 randomized to prophylactic nasogastric tube insertion for postoperative decompression, and 2087 randomized to no tube in the postoperative period. Those not having a routine NGT experienced an earlier return of bowel function (P < 0.001), and no significant differences in pulmonary complications, wound infection, ventral hernia or anastomotic breakdown.   NGTs can always be placed if symptoms of GI distention are worrisome.   Another meta-analysis[ii]  of twenty-six trials (3964 patients) found that you would need to place 20 prophylactic NGTs to avoid one postoperative insertion. 

 Another one of our colleagues from Olympia asked, “Don’t NGTs decrease post-operative nausea and vomiting?”

In a 2009 investigation[iii], a large multicenter study (International Multicenter Protocol to Assess the Single and Combined Benefits of Antiemetic Interventions or IMPACT) found that prophylactic NGT use was not associated with a reduction in nausea (odds ratio [OR] 1.22, 95% CI 0.92-1.60), vomiting (OR 0.92, 95% CI 0.66-1.29), or combined PONV (post-operative nausea and vomiting) (OR 1.23, 95% CI 0.93-1.61). The incidence of PONV in the first 24 hours after surgery was 44.4% in patients with an NG tube versus 41.5% in controls. These conclusions are important since routine NG tube placement may be associated with complications such as an increased incidence of sore throat and the rare risk of esophageal perforation.

It’s hard to eat with a tube in your nose, and multiple studies show the benefits of early feeding.

In a meta-analysis[iv] of 837 patients receiving an immediate diet had fewer postoperative infections, reduced anastomotic complications and shorter length of stay compared to patients who fasted until gastrointestinal functions were resumed.  Another randomized trial[v] included 316 patients and evaluated the feasibility and safety as well as the tolerance of early oral feeding in patients undergoing colorectal resections. They found reduced postoperative discomfort, accelerated return of bowel function, and improved rehabilitation outcomes in the early feeding group.  A randomized trial[vi] of 453 patients undergoing upper GI surgery studied early feeding vs. NPO status in upper GI surgery.  The operations were hepatic, pancreatic, esophageal, gastric resections, and bilioenteric and gastroenteric bypass procedures. Patients who were allowed to eat normal food at will from the first day after major upper GI surgery did not show an increase in morbidity compared with non-fed patients.

 Given the evidence above, what are the recommendations for NG tube use?

 SCOAP surgeons are aiming to reduce the use of NGTs among non-ventilated post-op patients. Avoiding a NGT makes it easier to begin oral feedings earlier in the perioperative period, allows patients to ambulate earlier and may decrease the risk of post-operative complications.  As you can see above there is also an abundance of Class 1 evidence to support this approach.

 What strategies have worked at other hospitals to decrease NG use?

Some SCOAP hospitals have added the step of NG tube removal in their Surgical Checklist (to make sure that a tube placed by the anesthesia team does not remain in the postoperative period and to raise awareness of the issue). Others have shared their SCOAP data with surgeons who have a high rate of routine NG tube use to show how their practice compares to others throughout the state. Often the conversation links their use of NGTs to longer length of stays.  It is also helpful to work closely with anesthesia providers, include NG tube removal in post-operative order sets and to include this component in any protocols that are developed for colorectal surgery GI recovery.

[i] Nelson R, Tse B, Edwards S. Systematic review of prophylactic nasogastric decompression after abdominal operations. Br J Surg. 2005 Jun;92(6):673-80

[ii] Cheatham M L, Chapman W C, Key S P, Sawyers J L. A meta-analysis of selective versus routine nasogastric decompression after elective laparotomy. Ann Surg. 1995; 221:469–478.

[iii] Kerger KH, Mascha E, Steinbrecher B, Frietsch T, Radke OC, Stoecklein K, Frenkel C, Fritz G, Danner   K, Turan A, Apfel CC, Routine use of nasogastric tubes does not reduce postoperative nausea and vomiting. Anesth Analg 2009 Sept 109(3):768-73

[iv] Lewis SJ, Egger M, Sylvester PA, Thomas S: Early enteral feeding versus “nil by mouth” after gastrointestinal surgery: systematic review and meta-analysis of controlled trials.  BMJ 2001, 323:773-776

[v] Zhou T, Wu XT, Zhou YJ, Huang X, Fan W, Li YC. Early removing gastrointestinal decompression and early oral feeding improve patients’ rehabilitation after colorectostomy. World J Gastroenterol 2006; 12(15): 2459-2463

[vi] Lassen, K., Kjoeve, J., Fetveit, T., Trana, G., Kjartan, H., Horn, A., Revhaug, A.  Allowing Normal Food at Will After Major Upper Gastrointestinal Surgery Does Not Increase Morbidity: A Randomized Multicenter Trial.  Annals of Surgery, 2008; 247(5), 721-729.


Research Opportunities in SCOAP

SCOAP’s core mission is to improve quality through tracking and intervention.  Occasionally our interests in quality improvement dovetail with researchers and the research funding priorities of Federal agencies, private foundations, and other healthcare stakeholders.  SCOAP is pleased to announce two recently funded projects from Agency for Healthcare Research and Quality (AHRQ) and National Cancer Institute (NCI) that help SCOAP accomplish its core mission while advancing knowledge.

 Collaborative to Improve Native Cancer Outcomes (National Cancer Institute)
 An award from the National Cancer Institute will provide support for SCOAP to develop a set of process and outcomes metrics specific to surgical treatment for common cancers including lung, breast, and prostate.  The Collaborative to Improve Native Cancer Outcomes is a multi-faceted program funded to improve cancer health outcomes and quality of life for American Indian and Alaskan Native patient population, which experiences dramatic health inequities. 

In collaboration with Lead Investigators Dr. Dedra Buchwald (University of Washington) and Dr. Jeffrey Henderson (Black Hills Center for American Indian Health), SCOAP is pleased to participate in this meritorious effort in improving health care delivery to Washington State patients.  Our invited efforts include the development of new sets of metrics for lung, prostate and breast cancer and then tracking the use of surgical treatment and outcomes in these cancers across SCOAP hospitals.  We plan to study patterns of surgical care and clinical outcomes across all patient populations to evaluate health disparities and identify best practices for improvement in care delivery to disadvantaged populations. 

The SCOAP dataset was modified in Q1 of 2010 to have more specific tracking of race and ethnicity and the new cancer-specific module developing from this effort will be available in 2011 to all SCOAP hospitals ready to expand into surgical cancer quality improvement.  If your hospital has a large American Indian or Alaskan Native population and you are interested in partnering with us in the investigative effort, please contact us.

Communication to Prevent and Respond to Medical Injuries (Agency for Healthcare and Research Quality)
Effective team communication is a key ingredient of safe care.   Improving open surgical team communication has been a focused effort of the SCOAP surgical checklist initiative, and our collective efforts have been recognized through a new award from the Agency for Healthcare and Research Quality studying the impact of successful communication training and strategies on patient safety and malpractice liability. 

The focus of this study is on communication-sensitive events including National Quality Forum never-events, medication errors, and surgical checklist failures.  In this project, SCOAP will partner with national leaders in patient safety and team communication to implement a communication-sensitive event registry and measure the impact training and strategies on improving patient care.   In addition, five partner healthcare institutions will implement an innovative approach to joint adverse event analysis, disclosure, and compensation for patients in a multi-institution, multi-insurer setting.  The end-goal of this project is to deploy a statewide e-learning communication training module based on the most successful strategies.

If your hospital is interested in partnering with us in the initial years of implementing communication training and registries, please contact us.

SCOAP Community Speaks Up: Value in SCOAP

We were recently asked by administrators at Virginia Mason Medical Center about the “return on investment” associated with SCOAP.

To state the obvious:  these are lean financial times for hospitals.  Being a part of SCOAP costs hospitals money, and that investment requires that SCOAP adds value. 

Quantifying the Investment
The costs of SCOAP include a yearly fee to the Foundation for Healthcare Quality to run the program.  That fee ranges based on hospital size (critical access hospitals pay $1,000-$3,000, and larger hospitals pay $5,000-$10,000) and is higher if the hospital participates in additional modules (e.g., VI-SCOAP for vascular and interventional care includes an additional fee of $5,000).  These yearly fees have been stable since we started 4 years ago and will be increasing in the next year as the interactive functionality of the data reporting system increases and as we work toward the sustainability of SCOAP.   SCOAP hospitals also have to pay to extract data from its systems.  In many centers, this is done through local abstractors (approximately .3 FTE at a mid-sized hospital doing general SCOAP but greater at larger hospitals and those involved in more modules).  Increasingly, this work is being performed by “outsourced” personnel (contact for more information) or by automating extraction from existing data systems.  There is also staff time involved at hospitals in looking at SCOAP performance reports and organizing and participating in work groups to address areas of underperformance.  At different hospitals, this set of fees, data costs, and response functions may range in price from $5,000 to $50,000.  So, to paraphrase the question raised at VMMC but felt across the state, is SCOAP worth it?  And as SCOAP services, focus areas, data types, and fees increase, will our 55+ member hospitals remain members, or is SCOAP simply a good idea that is unsustainable in these financial times?

Part of the problem with the framework of this question is that, despite all its talk about safety, the healthcare industry has never really put a premium on it.  Hospitals simply do not spend money on performance monitoring around safety and quality at a rate anything close to other high risk industries.  Nuclear power, chemical manufacturing and aviation spend approximately 20-30% of their overhead on safety, monitoring systems, and performance improvement.1  The costs of a program like SCOAP, as well as most of a hospital’s programs for quality, are the equivalent of rounding errors in a hospital’s yearly budget.  A hospital’s QI department is usually filled with some of the most earnest, hard working, and passionate employees, working with some of the most resource-limited and cash-strapped budgets.  Compare the money hospitals spend on meaningful performance benchmarking to the money it spends on little used robotic assistants, advertising on billboards, and creating VIP services.  Part of the problem is that incentives are not well aligned to justify big investments in quality – surgeons get paid by insurers for an original operation as well as repeat operations for complications, DRGs get up-coded, and insurers pay more for complicated care. Insurance payments to hospitals do not build in a buffer for anything close to 20-30% for QI interventions, and most hospitals have only 1-3% profit margins.  While all this may change someday, we live in the present, and SCOAP is left defining its value despite the relatively low costs of the program.

Defining Value
There are many domains of value, and value is sometimes defined as being in the eyes of the beholder.  Let’s start by looking at the SCOAP metrics.  The SCOAP metrics at the core of the SCOAP performance benchmarking reports that hospitals “get” for their fees are picked by leading academics in surgical QI and science and community practice surgeons with years of experience.  SCOAP metrics are chosen based on cutting-edged evidence – these are the things we know define success in surgery.  There are over 100 SCOAP metrics that surgeons use to define and achieve success.  These are not data points that hospitals had before SCOAP, nor would they have them if SCOAP went away.  Only a fraction of these (<5) are SCIP or core measures (that among Medicare patients hospitals have to gather data on anyway), and on many of these metrics your hospital is “underperforming” the average, let alone achieving a best performers benchmark.  What is it worth to know that your hospital is underperforming on measures that your own clinicians define as keys to success and safety? While economists have complex formulas for actually figuring that out, most CFOs and CEOs see excellence as a key component of their strategic vision for financial success.  Knowing about underperformance is the first step to addressing its threat to financial success.  In fact, the temporal trend data from this year’s SCOAP annual reports show that at every hospital, some of these metrics are getting better.  SCOAP works to drive improvement through shining a spotlight on areas of underperformance, but also through interventions like the SCOAP Surgical Checklist (, that change the culture of surgery from within.  Since no hospital is meeting the benchmark for all of the measures, every hospital administrator has to decide whether shutting off performance benchmarking data in a setting of known underperformance is a smart financial calculation.

However, it’s not just about getting data on underperformance.  With SCOAP, Washington State is creating a community of surgeons who are actually engaged with these data and feel as if they “own” the data fields and the process of benchmarking and system response.  Engaged surgeons mean cooperative partners in QI, not obstructionists or reluctant staff.  Getting the engagement of clinicians is not something that can be bought – it is priceless.  SCOAP builds engagement through newsletters, teleconferences, regional and statewide meetings, and an increasing national recognition that Washington State surgeons have done something really special that is worth being a part of.  That is the opposite of what “top-down” SCIP-style initiatives are, in which Medicare says we have to do it so we do it, grumbling all the way.  While hospitals can try to quantify the value of engagement, a better question they may ask is whether they really think they can achieve the massive needed improvements in QI and cost-effectiveness and reductions in inappropriate care with SCIP-like initiatives.  Tackling these difficult thorny issues will require just this kind of engagement and the buy-in of the clinical community that is at the center of SCOAP.  SCOAP is helping to build a community of surgeons willing to standardize what they do and setting the groundwork for the standardization movement coming down the track.

This article was intended to answer the question about value, so let’s go back to counting real dollars saved.  Four years of monitoring has shown us that hospitals in SCOAP have lower rates of expensive complications, shorter lengths of stay, and use fewer expensive resources than non-SCOAP hospitals and improve on these domains quarter by quarter.  At hospitals trying to look at the value of SCOAP, they should first look at their last SCOAP report to see if they meet the high-performance benchmark on avoiding prolonged length of stay (metric 20.1 on SCOAP reports), reoperative complication (metric 19.2), and high burden complications like reintubations (metric 12.1).  (View a demo report here [username scoap; password demo].  Contact Rosa Johnson for information on obtaining your hospital’s report).   These metrics hurt hospital profitability, especially for hospitals that receive DRG payments, because even though the costs of complications are spread back to insurers, hospitals lose most of their profit margin (23% reduces to 3.4%) with each complication.2  In another study performed by Dimick et al in the Michigan NSQIP collaborative,3 reductions in complications of even small amounts per year balanced the costs of the NSQIP platform (with abstractor time included) to a single insurer.  SCOAP has had an average yearly reduction in major reoperative complications of 0.5%.

Complications in surgery cost every aspect of the healthcare system.  In fact, when viewing the entire state of Washington over the 5 years it has taken to get to near universal SCOAP enrollment, non-SCOAP hospitals cost the system dramatically more than SCOAP hospitals, according to the SCOAP-released white paper on SCOAP costs (.pdf).  SCOAP hospitals have literally “bent the cost curve,” flattening year-on-year costs of care and reducing projected costs by over $50 million for just three SCOAP procedures (appendectomy, bariatric surgery and colectomy).  Being able to flatten the cost curve will be even more important as we move to more accountable care experimentations in the current reform environment.  As reform evolves, SCOAP will be providing information on rehospitalizations and patient-reported outcomes that will be central to these initiatives.  Being in SCOAP now means being a top performer in the future healthcare system too.

SCOAP also adds value in the here and now.  While the future real impact of pay for performance or participation is in evolution, SCOAP directs energy to improving these (think VTE prophylaxis, a SCIP measure and the SCOAP surgical checklist initiative) as well as getting more timely data on performance improvement on a more robust sample size of patients so that the success of initiatives can be assessed (not just Medicare patients).  Most hospitals see the value in “checking in the boxes” of these P4P metrics and SCOAP helps accomplish this.  In fact, according to Medicare’s Hospital Compare, SCOAP hospitals do better than non-SCOAP hospitals on SCIP measures, circling back to the power of engaged clinicians in QI. 

Lastly, being a member of the SCOAP collaborative asserts the role of your hospital in the broader community of hospitals.  Your hospital’s clinicians become state leaders in an evolving and cutting edge QI and cost-effectiveness program.  Clinicians who are defined by the state as leaders in quality are a great way to draw patients.  SCOAP puts your hospital and your doctors ahead of the curve and in the lead for QI, and what patient seeks out a hospital because their doctors are average on SCIP measures?  SCOAP also helps your hospital save FTEs around data collection for credentialing, meeting a surgeon’s requirements for American Board of Surgery Maintenance of Certification Part 4, and helping hospitals bring on new clinicians without having to invest in additional quality monitoring to make sure the care they deliver is excellent. 

Lastly, the community has spoken about SCOAP.  The Governor’s office, 55+ hospitals, and the public now look to SCOAP as a force for positive change in the healthcare community and as an example of clinicians “owning” quality.  The alternative is a state legislature that feels it has to own QI and the potential costs of that for our system, both politically and through resources related to reporting on “their” metrics.

Hospital administrators will determine the success of SCOAP based on whether they find sufficient value in the program.  Doctors, nurses, techs, patients, and payers need to show they value SCOAP as a vehicle for improving surgical care.  When hospitals make resource decisions, we encourage them to consider all the domains of value defined above.  Washington State hospitals are writing an inspiring story about the power of clinician engagement in improving care.  The future impact and scope of SCOAP depends on the value seen in their investment, and we are hopeful that this story ends well. 

Our patients depend on it.

Thanks for all you do to make SCOAP what it is.


  1. Horder P. Airline Operating Costs. Presentation at Managing Aircraft Maintenance Costs Conference. Brussels: January 22, 2003. (Slides
  2. Dimick JB, Weeks WB, Karia RJ, Das S, Campbell DA Jr. Who pays for poor surgical quality? Building a business case for quality improvement. J Am Coll Surg. 2006 Jun;202(6):933-7.
  3. Englesbe MJ, Dimick JB, Sonnenday CJ, Share DA, Campbell DA Jr. The Michigan surgical quality collaborative: will a statewide quality improvement initiative pay for itself? Ann Surg. 2007 Dec;246(6):1100-3.

SCOAP Surgical Checklist Initiative: After 100%

On March 22nd at the Museum of Flight, SCOAP and the SCOAP Surgical Checklist Coalition celebrated the remarkable achievement of 100% adoption of The SCOAP Surgical Checklist by all hospitals across Washington State!  The goal of 100% adoption was set in January 2009, and it is thanks to the Washington State healthcare community’s dedication to patient safety that the goal was met in one year.

 The SCOAP Surgical Checklist initiative has attracted a wide range of supporters and interested parties, and the broad range of attendees reflected this.  The audience gathered at this milestone event included clinicians, nurses, quality improvement professionals, hospital executives, national and regional representatives from the insurance industry, representatives from corporate organizations, healthcare professional organizations, and media.  Governor Gregoire and Washington State Senator Karen Keiser of the Health & Long-Term Care Committee both sent statements of support and congratulations for the successful 100% adoption of the SCOAP Surgical Checklist.

 This great achievement was possible only through the combined efforts of a wide-ranging group of people and organizations.  These organizations and the individuals who gave their time to this effort are many and include: 

  • Foundation for Healthcare Quality
  • Life Sciences Discovery Fund
  • The SCOAP Surgical Checklist Coalition, a grass roots multi-stakeholder collaborative which included representatives from many organizations:
    • Professional organizations
      • Association of Surgical Technologists (Sandra Manwiller)
      • Northwest Organization of Nurse Executives  (Gladys Campbell)
      • Washington Association of Nurse Anesthetists (Frank Maziarski, Mary Lawlor)
      • Washington State Society of Anesthesiologists (John Bramhall)
      • Washington State Chapter of the American College of Surgeons (Marc Horton)
      • Washington State Council of Perioperative Nurses (Debbie Amos)
      • Washington State Hospital Association (Carol Wagner, Beth Zbrowski)
      • Washington State Medical Association (Jennifer Hanscom, John Arveson)
      • Washington State Nurses Association (Sally Watkins)
    • Insurance providers
      • Aetna
      • FirstChoice Health
      • Group Health
      • Premera Blue Cross
      • Physicians Insurance
      • Uniform Medical Plan
    • Consumer groups and governmental agencies
      • Health Care Authority (Nancy Fischer)
      • King County (Kerry Schaefer)
      • Puget Sound Health Alliance (Diane Stollenwork)
      • Washington State Department of Social and Health Services (Jeff Thompson)
  • The SCOAP Surgical Checklist Metrics Committee, which assists in checklist content decisions.  The metrics committee includes members from the SCOAP Surgical Checklist Coalition as well as Dr. Larry Schecter of Providence Regional Medical Center Everett and Roger Strand of The Everett Clinic.
  • Corporate partners
    • Aetna
    • Costco
    • Emphatic Communications
    • Merck,
    • Sanofi-Aventis
    • Washington State Business Roundtable

 SCOAP and the SCOAP Surgical Checklist Coalition look forward to continuing to support hospitals, clinicians and surgical teams in their goal of delivering high quality and safer surgical care.  This is not the end of the initiative, but simply the beginning of the next phase. Our work here is all part of a movement that will end only when the systems built around healthcare make surgeries safer for our patients.  We still have the hard work of making sure that in every operation the checklist is used, that opting out is not an option, that systems align incentives to encourage its use, and that systems be willing to penalize those who refuse to change their own behavior. 

 The checklist also needs to evolve as new evidence emerges.  We don’t know everything yet about how to make perfect procedures.  As the science evolves, so too will the checklist.  Additionally, use of the checklist needs to expand to the other places where healthcare happens and needs to cover steps in procedures well beyond the beginning and end of an operation.  There is much work to do, but this step of 100% adoption is a great start, and we thank you for all you’ve done to be a part of that.