Sustainable Quality Improvement Through Statewide Collaboratives

Since the time of Ernest Codman, surgeons have understood that the measurement of surgical outcomes can be used for the improvement of care. While Codman gained little traction among the Boston surgical establishment, during the last quarter century there has been exponential growth and acceptance of surgical quality improvement (QI). From well-known, longitudinal national efforts, such as the American College of Surgeons National Surgical Quality Improvement Program to more targeted projects, such as the Safe Surgery South Carolina Program, the fund of knowledge, stakeholder engagement, and data supporting the value of QI work continues to grow.¹ The accompanying article by Bilimoria et al.² describes the Illinois Surgical Improvement Collaborative (ISQIC), which provides a strong model for the formation and funding of sustainable QI efforts that benefit patients and hospital systems in the long term.

Hospitals and health systems often engage in reactive QI efforts, such as interventions to address specifically identified safety or outcome deficits; the development of ISQIC represents a comprehensive and sustainable approach to ongoing surgical QI for a diverse range of hospitals across the state.³ ISQIC’s emphasis on improving patient outcomes, providing education in QI methods, enhancing data collection and analysis capabilities, and developing QI tools highlights the challenges and benefits of achieving effective and sustainable quality improvement efforts on a large scale.

ISQIC engaged in several foundational activities to establish the basis for its success. The collaborative identified areas of focus and established 21 strategies across 5 domains (guided implementation, education and training, comparative reports, networking, and financial support) through structured needs assessments. These initial activities were critical in enabling the collaborative’s QI work to be more immediately applicable, leading to increased member engagement. For example, initial feedback from stakeholders highlighted the need for formal training and mentorship for surgeons leading QI initiatives. As a result, ISQIC incorporated surgeon-specific training programs, which have been valuable additions to the collaborative’s initiatives.

ISQIC’s inclusion of surgeon-specific training and mentorship programs is just one part of a comprehensive approach to QI. Alongside in-person training and meetings, the development of a standardized data collection and reporting system now allows participating hospitals to benchmark their progress and share best practices. The results of this effort are impressive, with participating hospitals reporting improved communication and teamwork among surgical teams, increased engagement with QI efforts, and significant reductions in surgical site infection rates over a period of 3 years. This success demonstrates the value of a collaborative, data-driven approach to QI. This suggests that collaborative quality improvement initiatives can be effective in improving meaningful surgical outcomes and can be scaled to a statewide level.

In addition to improving patient outcomes, ISQIC also reduces healthcare costs through a shared savings model with payors. By implementing best practices and reducing the incidence of surgical site infection, participating hospitals can avoid the costs associated with treating these infections, resulting in significant cost savings for payers. This approach benefits patients by reducing their healthcare burden and helps to lower healthcare costs for payers and providers, ultimately leading to a more sustainable healthcare system. The success of ISQIC also highlights the importance of patient satisfaction, as reducing complications and improving outcomes can improve patients’ overall experience with surgical care and satisfaction with the healthcare system. Through this, they strive for the “triple aim” of healthcare quality as described by the Institute for Healthcare Improvement—improved health, better patient experience, and reduced costs.⁴

ISQIC faces complexities that are common to many QI initiatives, including funding challenges, sustaining stakeholder engagement, standardization, and QI culture development. As the authors note, creating comprehensive and large-scale QI initiatives presents a range of challenges, including the need for substantial funding. This is compounded by the variable nature of payor and reimbursement environments, especially when cost savings are expected to be realized immediately. ISQIC members rely on the use of the medical loss ratio associated with the largest insurer in their state. This approach is similar to the funding model used by the Michigan Surgical Quality Collaborative, which successfully engaged a large number of hospitals, including smaller and rural facilities, and those using bundled payment models.⁵ While both collaboratives have found success in this approach, it may not be reproducible to the same degree in other regions due to differences in payor mixes.

Moving forward, ISQIC has the potential to continue expanding its membership regionally, which may lead to a larger and more diverse dataset. This will enable ISQIC to identify new QI opportunities and target areas of improvement more effectively. Additionally, collaborating with other regional or national QI initiatives will facilitate the sharing of best practices and comparison of outcomes, and allow for the identification of areas for improvement. However, it is important to note that collaboratives based in different geographical areas or with vastly different patient populations may have different needs assessments that reveal components not included in the 21 identified by ISQIC. This may make direct reproducibility challenging.

It is well-recognized that meaningful QI is hard. It requires sustained commitment of resources, effort, and review. ISQIC’s success demonstrates the importance of involving stakeholders and implementing evidence-based interventions to improve surgical outcomes at the initial steps of collaborative development. Moreover, the program’s reduction in healthcare costs and improvement of patient satisfaction supports the idea that QI initiatives can have a significant impact on multiple aspects of surgical care delivery simultaneously. Ultimately, ISQIC highlights the potential for collaborative QI initiatives; although challenges and limitations exist, the initiative’s approach can serve as a model for other states and regions seeking to improve surgical outcomes and reduce costs. The authors have identified a fruitful area for reflection, discussion, and continued innovation in the delivery of high-quality surgical care to patients: the development of methods to identify areas for improvement, and perhaps more importantly to create, grow, and sustain a holistic quality improvement collaborative.