Abstract
In the interest of improving patient care quality and reducing costs, many hospitals across the nation participate in quality measurements. The three programs most applicable to colon and rectal surgery are the National Surgical Quality Improvement Project, the Surgical Care Improvement Project (SCIP), and the Surgical Care and Outcomes Assessment Program. Participation in each is variable, although many hospitals are eligible and welcome to participate. Currently, SCIP is the only one with a financial incentive to participate. This article will focus on participation; however, the motivation for such is elusive in the literature. It is likely that a combination of resource utilization and faith in the concept that participation results in improvements in patient care actually drive participation.
Keywords: NSQIP, SCIP, SCOAP, participation
CME Objective: On completion of this article, the reader should be able to summarize the level of participation in each program (NSQIP, SCIP, and SCOAP).
American College of Surgeons National Surgical Quality Improvement Project
The American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) describes itself thusly: “ACS NSQIP is a nationally validated, risk-adjusted, outcomes-based approach to measure and improve the quality of surgical care. It employs a prospective, peer-controlled, validated database to quantify 30-day, risk-adjusted surgical outcomes, which provide a valid comparison of outcomes among all hospitals in the program” (http://site.acsnsqip.org/join-now/faq/).1 The specifics of the program, including data collection, entry, and analysis as well as reporting, are outlined in another article, Current Status of Quality Measurement in Colon and Rectal Surgery.
The number of hospitals participating in NSQIP has increased greatly over time. In 2004, there were 18 participating hospitals.2 Today, there are more than 400. This Web site link (http://site.acsnsqip.org/participants/)3 lists all of the approximately 400 hospitals that participate in NSQIP. The Web site for NSQIP has easy to follow information on participation in the program. To become a participating hospital, the ACS NSQIP Web site provides an enrollment checklist (http://site.acsnsqip.org/wp-content/uploads/2013/02/NSQIP-Enrolllment-Checklist-2012C.pdf) as well as an online application for participation (http://www.acsnsqip.org/ApplicationOnline/).4
According to the American Hospital Association, there are roughly 5,181 registered hospitals in the United States. This number excludes nonfederal psychiatric hospitals, nonfederal long-term care hospitals, and hospital units of institutions (prison hospitals, college infirmaries, etc.). Of those, 4,973 are community hospitals. Community hospitals are defined as all nonfederal, short-term general, and other special hospitals whose facilities and services are available to the public.
Other special hospitals include obstetrics and gynecology; eye, ear, nose, and throat; rehabilitation; orthopedic; children's; and other individually described specialty services. Community hospitals include academic medical centers or other teaching hospitals if they are nonfederal short-term hospitals. Excluded are hospitals not accessible by the general public, such as prison hospitals or college infirmaries (http://www.aha.org/research/rc/stat-studies/fast-facts.shtml).5
Since there are approximately 400 hospitals that participate in NSQIP, this only amounts to approximately 7.7% of US hospitals that participate. Of course, there are some participation criteria that may limit some hospital participation, such as those not performing ACS NSQIP eligible cases. ACS NSQIP is available to hospitals of all types, urban and rural, large and small, and teaching and nonteaching. It offers different program options including:
Essentials—best suited for hospitals that want to collect only data applicable for quality improvement purposes.
Small and rural—best suited for hospitals that perform fewer than 1,680 cases per year or meet the rural-urban commuting area (RUCA) definition of rural hospital.
Procedure targeted—best suited for hospitals that are larger and would like to focus quality improvement (QI) efforts on specific higher risk procedures selected by the hospitals.
Pediatric—best suited for hospitals that want to measure the quality of children's care.
Measures—best suited for hospitals that have limited resources and need to focus QI efforts (http://site.acsnsqip.org/program-specifics/program-options/).6
Every state has at least one participating hospital except for Wyoming, New Mexico, North Dakota, and Mississippi. Table 1 lists the participation by state (these percentages are rough approximations, as the denominators are numbers for community hospitals, which represent 85% of all hospitals). Federal hospitals, long-term care hospitals, psychiatric hospitals, institutions for the mentally disabled, and alcoholism and other chemical dependency hospitals are not included.
Table 1. Percentage of NSQIP participating hospitals by state.
| Alabama | 2/105 = 2% |
| Alaska | 2/22 = 9% |
| Arizona | 2/73 = 3% |
| Arkansas | 1/85 = 1% |
| California | 54/343 = 16% |
| Colorado | 8/80 = 10% |
| Connecticut | 11/34 = 32% |
| Delaware | 2/7 = 29% |
| District of Columbia | 1/11 = 9% |
| Florida | 48/210 = 23% |
| Georgia | 11/154 = 7% |
| Hawaii | 7/26 = 27% |
| Idaho | 3/41 = 7% |
| Illinois | 18/189 = 10% |
| Indiana | 10/125 = 8% |
| Iowa | 6/118 = 5% |
| Kansas | 1/130 = 0.8% |
| Kentucky | 5/106 = 5% |
| Louisiana | 3/126 = 2% |
| Maine | 12/37 = 32% |
| Maryland | 9/47 = 19% |
| Massachusetts | 17/79 = 22% |
| Michigan | 14/156 = 9% |
| Minnesota | 10/133 = 8% |
| Mississippi | 0/96 = 0% |
| Missouri | 10/122 = 8% |
| Montana | 4/48 = 8% |
| Nebraska | 4/88 = 5% |
| Nevada | 2/36 = 6% |
| New Hampshire | 2/28 = 7% |
| New Jersey | 8/73 = 11% |
| New Mexico | 0/36 = 0% |
| New York | 31/185 = 17% |
| North Carolina | 20/117 = 17% |
| North Dakota | 0/41 = 0% |
| Ohio | 13/183 = 7% |
| Oklahoma | 2/113 = 2% |
| Oregon | 9/58 = 16% |
| Pennsylvania | 16/196 = 8% |
| Rhode Island | 2/11 = 18% |
| South Carolina | 2/67 = 3% |
| South Dakota | 1/53 = 2% |
| Tennessee | 24/134 = 18% |
| Texas | 27/426 = 6% |
| Utah | 3/44 = 7% |
| Vermont | 1/14 = 7% |
| Virginia | 11/89 = 12% |
| Washington | 5/86 = 6% |
| West Virginia | 1/56 = 2% |
| Wisconsin | 7/124 = 6% |
| Wyoming | 0/24 = 0% |
Abbreviation: NSQIP, National Surgical Quality Improvement Project.
Collaboratives have been formed within the NSQIP community. Collaborative are groups of the ACS NSQIP participating hospitals that come together to discuss best practices, quality improvement initiatives, and/or to compare their surgical outcomes in a positive learning environment (http://site.acsnsqip.org/participants/collaboratives/).7 Currently, more than 20 collaborative groups exist or are in development. Currently, these are organized based on location (i.e., regional Connecticut, Upstate, New York), hospital system (Kaiser Permanente, Mayo), or disease based (colectomy, glucose control).
Surgical Care Improvement Project
The Surgical Care Improvement Project (SCIP) is a national quality partnership of organizations interested in improving surgical care by significantly reducing surgical complications. Further details about the origins and current status are provided in another article, Current Status of Quality Measurement in Colon and Rectal Surgery.
Currently, 2,984 hospitals participate in SCIP by reporting certain defined process measures to Medicare. These include: (1) prophylactic antibiotic preoperative timing, (2) prophylactic antibiotic selection, (3) prophylactic antibiotic discontinuation within 24 hours (48 hours for cardiovascular surgery) after surgical end time, (4) cardiac surgery patients with controlled 6 am postoperative blood glucose postoperative day 1 (POD1) and day 2 (POD2), (5) hair removal, (6) temperature management with immediate postoperative normothermia, (7) β-blocker therapy, (8) venous thromboembolism prophylaxis (not required for outpatients), and (9) urinary catheter removal—POD1 or POD2.
Participation in SCIP, and thus collection of all of these data points by hospitals, is voluntary. However, hospital participation in reporting SCIP measures is likely more robust than other process or outcome measures because the Centers for Medicare and Medicaid Services reduces hospital reimbursement by 2% if they fail to report their performance on these measures.8 There is currently a great deal of discussion in health care surrounding quality, quality measurements, and reimbursement. The Medicare Web site (Medicare.gov) notes that the Hospital Value-Based Purchasing (Hospital VBP) Program, established by the Affordable Care Act, implements a pay-for-performance approach to the payment system that accounts for the largest share of Medicare spending—affecting payment for inpatient stays in approximately 3,000 hospitals across the country. Under Hospital VBP, Medicare is adjusting a portion of payments to hospitals beginning in Fiscal Year 2013 based on either: (1) how well they perform on each measure compared with all hospitals, or (2) how much they improve their own performance on each measure compared with their performance during a prior baseline period (http://www.medicare.gov/hospitalcompare/linking-quality-to-payment.aspx).9
Although adherence to SCIP measures has certainly increased since its inception in 2006, it remains controversial as to whether or not this actually translates into improvements in surgical outcomes at the hospital or patient care level.10 Nevertheless, the patient can look up individual hospitals to determine adherence to the SCIP measures. Hospital Compare is a section of the Medicare Web site where one can type in a location and/or hospital, and get back data on adherence to each SCIP measure (http://www.medicare.gov/hospitalcompare/search.aspx).11
Surgical Care and Outcomes Assessment Program
Surgical Care and Outcomes Assessment Program (SCOAP) was created to benefit hospitals, surgeons, and patients in the state of Washington by improving quality of care (Tables 2 and 3). SCOAP participants receive regular reports of hospital-level data that allow them to compare and track their own processes and outcomes.
Table 2. The following hospitals are currently participating in SCOAP.
| Auburn Regional Medical Center | Auburn |
| Capital Medical Center | Olympia |
| Central Washington Hospital | Wenatchee |
| Coulee Community Hospital | Grand Coulee |
| Evergreen Hospital Medical Center | Kirkland |
| Forks Community Hospital | Forks |
| Franciscan Health System | |
| St. Joseph Medical Center | Tacoma |
| St. Francis Hospital | Federal Way |
| St. Clare Hospital | Lakewood |
| St. Elizabeth Hospital | Enumclaw |
| St. Anthony Hospital | Gig Harbor |
| Grays Harbor Community Hospital | Aberdeen |
| Group Health Cooperative/Seattle | Seattle |
| Harborview Medical Center | Seattle |
| Highline Medical Center | Burien |
| Island Hospital | Anacortes |
| Jefferson Healthcare | Port Townsend |
| Kadlec Medical Center | Richland |
| Legacy Good Samaritan Hospital & Medical Center | Portland, OR |
| Lincoln Hospital | Davenport |
| Madigan Army Medical Center | Tacoma |
| Mason General Hospital | Shelton |
| Morton General Hospital | Morton |
| MultiCare | |
| Good Samaritan Hospital | Tacoma |
| Mary Bridge Children's Hospital | Puyallup |
| Tacoma General Allenmore Hospital | Tacoma |
| Northwest Hospital & Medical Center | Seattle |
| Ocean Beach Hospital | Ilwaco |
| Olympic Medical Center | Port Angeles |
| Othello Community Hospital | Othello |
| Overlake Hospital Medical Center | Bellevue |
| Peace Health St. Joseph Medical Center | Bellingham |
| Peace Health St. John Medical Center | Longview |
| Prosser Memorial Hospital Medical Center | Prosser |
| Providence Holy Family Hospital | Spokane |
| Providence Sacred Heart Medical Center & Children's Hospital | Spokane |
| Providence St. Mary Medical Center | Walla Walla |
| Samaritan Hospital | Moses Lake |
| Seattle Children's | Seattle |
| Skagit Valley Hospital | Mount Vernon |
| Skyline Hospital | White Salmon |
| Southwest Washington Medical Center | Vancouver |
| Sunnyside Community Hospital | Sunnyside |
| Swedish Health Services/Cherry Hill Campus | Seattle |
| Swedish Health Services/Edmonds Campus | Edmonds |
| Swedish Health Services/First Hill Campus | Seattle |
| United General Hospital | Sedro-Woolley |
| University of Washington Medical Center | Seattle |
| Valley Medical Center | Renton |
| Virginia Mason Medical Center | Seattle |
| Walla Walla General Hospital | Walla Walla |
| Wenatchee Valley Medical Center | Wenatchee |
| Whidbey General Hospital | Coupeville |
| Whitman Hospital & Medical Center | Colfax |
| Yakima Regional Medical & Cardiac Center | Yakima |
Abbreviation: SCOAP, Surgical Care and Outcomes Assessment Program.
Table 3. The following hospitals are currently not participating in SCOAP.
| Cascade Valley Hospital | Arlington |
| Harrison Memorial Hospital | Bremerton |
| Kennewick General Hospital | Kennewick |
| Kittitas Valley Community Hospital | Ellensburg |
| Legacy Salmon Creek | Vancouver |
| Mid-Valley Hospital | Omak |
| Providence Centralia Hospital | Centralia |
| Providence Mount Carmel Hospital | Colville |
| Providence St. Peter Hospital | Olympia |
| Toppenish Community Hospital | Toppenish |
| Valley General Hospital | Monroe |
| Valley Hospital and Medical Center | Spokane Valley |
| Yakima Valley Memorial Hospital | Yakima |
Abbreviation: SCOAP, Surgical Care and Outcomes Assessment Program.
The SCOAP program offers the following disclaimer: “Participation in SCOAP is voluntary. An important goal of SCOAP is to avoid coercive measures and create an atmosphere of collaboration and partnership in an effort to better serve patients in this state. The value that SCOAP provides—procedure and disease specific, clinically pertinent, timely information for quality improvement—will help hospitals with their decisions to participate in SCOAP” (http://www.scoap.org/background#question6).12 Participation in SCOAP does not preclude participation in other national programs. Hospitals can inquire about participation on the Web site by contacting the program and setting up a meeting with program staff. As an additional incentive, participation in SCOAP may allow proof of participation in the American Board of Surgery fourth part of maintenance of certification, currently mandatory for recertification.
Conclusion
Participation in NSQIP, SCIP, SCOAP, and other quality improvement initiatives is growing. How this may be translating into improved patient care will be discussed in detail throughout the articles in this issue. However, it is evident that participation in large, organized quality improvement initiatives involves only a minority of all hospitals in the country. Hopefully, as these programs become more all encompassing, it will result in the nationwide health care improvements for which we all strive.
References
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