How do they measure up?
Program gauges surgery services at rural hospitals
For resource-strapped rural hospitals, measuring surgical quality is critical not only for spurring improvement efforts but also for retaining local patient populations. “Rural hospitals sometimes get a bad rap,” says Dr. Clifford Ko, director of the American College of Surgeons’ division of research and optimal patient care, and the director of its National Surgical Quality Improvement Program, known as ACS NSQIP. “Patients might feel like they need to travel to the big city for surgery, so it’s advantageous for rural hospitals to show that they’re doing a great job.”
Created in 2004, the ACS NSQIP provides risk-adjusted outcomes data to participating hospitals, based on reviews of postoperative information in patient charts. The program focuses on measuring rates of complications such as surgical-site infections and urinary-tract infections, as well as 30-day mortality, Ko says.
A little more than a year ago, motivated by feedback from providers, the ACS added a special module to the program, customized for the needs of small and rural hospitals.
“It takes into account the types of cases that are usually done in these hospitals as well as the resources that a typical rural facility will or will not have,” Ko says.
The rural version of the program requires fewer cases and uses a smaller set of variables. The customized module also comes with a hefty price reduction that Ko says makes it more feasible for such providers. While the price tag for the ACS NSQIP’S classic program is roughly $30,000, the rural program costs about $10,000.
And while participants in the regular program are required to have a full-time surgical clinical reviewer, rural and smaller facilities can designate a part-time employee to assess the data, he adds. The rural program also gives surgeons opportunities to network with one another and to combat professional isolation.
“They not only have benchmark data but they have access to five people they can call if they, for instance, want to see how another hospital in a similar setting fixed their UTI rate,” he says.
Rural facilities need to participate in quality-improvement projects and be able to reach and maintain the same quality targets as their large urban peers, argues Dr. Howard Mccollister, chief of surgery at Cuyuna Regional Medical Center, a 25-bed critical-access hospital in Crosby, Minn., a town of less than 2,400.
“You can’t say rural outcomes are not as good so we’ll make allowances,” Mccollister says. “You have to be willing to hold your own feet to the fire. The University of Minnesota is two hours away. We’d better be able to do a colon resection as well as them and, if not, I should send my patients there instead.”
Despite its rural setting, Cuyuna Regional has built a well-known surgery department. Mccollister says that credibility is bolstered by transparency about patient outcomes.
Using the ACS NSQIP, the hospital has confirmed high levels of performance in many surgical areas and has also addressed problems as they arose, he says. For example, when it became apparent that Cuyuna Regional had higher-than-average rates of UTIS, the hospital traced the infections to frequent use of Foley catheters. After implementing new guidelines and training nurses in evidence-based practices, the hospital’s UTI rate fell to well below the national norm within 18 months.
“It’s insidiously easy to rationalize your complications,” Mccollister says. “Things slip your mind and the impression you have of the work that you do is not always right. Outcomes measures are extremely important
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