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SPECIAL ARTICLE

The Comparative Assessment and Improvement


of Quality of Surgical Care in the Department
of Veterans Affairs
Shukri F. Khuri, MD; Jennifer Daley, MD; William G. Henderson, PhD

rompted by the need to assess comparatively the quality of surgical care in 133 Veterans Affairs (VA) hospitals, the Department of Veterans Affairs conducted the National
VA Surgical Risk Study between October 1, 1991, and December 31, 1993, in 44 VA
medical centers. The study developed and validated models for risk adjustment of 30day morbidity and 30-day mortality after major surgery in 8 noncardiac surgical specialties. Similar models were developed for cardiac surgery by the VAs Continuous Improvement in Cardiac
Surgery Program. Based on the results of the National VA Surgical Risk Study and the Continuous
Improvement in Cardiac Surgery Program, the VA established in 1994 a VA National Surgical Quality Improvement Program (NSQIP), in which all the medical centers performing major surgery
participated. An NSQIP nurse at each center oversees the prospective collection of data and their
electronic transmission for analysis at 1 of 2 data coordinating centers. Feedback to the providers
and managers is aimed at achieving continuous quality improvement. It consists of (1) comparative, site-specific, and outcome-based annual reports; (2) periodic assessment of performance;
(3) self-assessment tools; (4) structured site visits; and (5) dissemination of best practices. The
NSQIP also provides an infrastructure to enable the VA investigators to query the database and
produce scientific presentations and publications. Since the inception of the NSQIP data collection process, the 30-day postoperative mortality after major surgery in the VA has decreased by
27%, and the 30-day morbidity by 45%. The future of the NSQIP lies in expanding it to the private
sector and in enhancing its capabilities by incorporating additional measures of outcome, structure, process, and cost.
Arch Surg. 2002;137:20-27
The Veterans Health Administration in the
Department of Veterans Affairs (VA) is the
largest single health care provider in the
United States. It comprises more than 159
medical centers, 376 outpatient clinics, and
165 long-term care facilities. One hundred
twenty-eight VA medical centers perform
major surgery, of which 42 perform cardiac surgery. Since the mid 1980s, the VA
has been expending major efforts in the development and application of systems for the
comparative assessment and improve-

From the Veterans Affairs Boston Healthcare System, West Roxbury (Drs Khuri and
Daley), and Brigham and Womens Hospital (Dr Khuri) and Institute for Health Policy,
Massachusetts General Hospital/Partners Healthcare System (Dr Daley), Harvard
Medical School, Boston, Mass; and Hines Veterans Affairs Cooperative Studies
Program Coordinating Center, Hines, Ill (Dr Henderson).

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20

ment of the quality of surgical care in the


various VA medical centers that perform cardiac and noncardiac surgery. The efforts in
cardiac surgery have culminated in the establishment of the Continuous Improvement in Cardiac Surgery Program,1 while the
efforts in noncardiac surgery have resulted
in the establishment of the VA National
Surgical Quality Improvement Program
(NSQIP). The NSQIP, which also collects
data for the Continuous Improvement in
Cardiac Surgery Program, is the first nationally validated, outcome-based, riskadjusted, and peer-controlled program for
the measurement and enhancement of the
quality of care in major surgical specialties.2 This article describes the evolution,
methods, and future plans of the NSQIP.

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BACKGROUND
The Congressional Mandate
The need for a proper system for the comparative assessment of the quality of surgical care in 133 VA hospitals
became critical after the US Congress passed a law in December 1986 that mandated that the VA report its surgical outcomes annually compared with the national average, and that these outcomes should be adjusted for
the severity of patients illnesses. A group of VA surgeons who were asked to consult with the VA Central
Office on how to respond to the congressional mandate
advised that there had been no known national averages
for outcomes of surgical procedures and no known risk
adjustment models that could be applicable to the various surgical specialties. They recognized, however, that
the VA, by virtue of its centralized authority and its advanced medical informatics infrastructure, was in a unique
position to develop national averages and risk adjustment models, and to set up a model system for the comparative assessment of the quality of surgical care among
its various institutions. Toward that goal, these surgeons prompted the VA to conduct the National VA Surgical Risk Study (NVASRS) between October 1, 1991, and
December 31, 1993, in 44 VA medical centers.3-5 The study
was conducted by an executive committee composed of
VA surgeons, health services researchers, and biostatisticians. An advisory panel of experts from outside the VA
provided the scientific oversight for the design and conduct of the study (Table 1).
The Rationale
The rationale underlying the NVASRS was based on Iezzonis algebra of effectiveness (Figure 1), a conceptual framework in which outcomes of health care are determined by the sum of 3 major factors: patients risk
factors before surgery, the effectiveness (quality) of the
patients care, and random variation.6 If one accounts for
the severity of the patients illnesses by proper risk adjustment and for random events by proper statistical methods, one can then equate outcome with effectiveness of
care. Hence, to enable the use of outcome as a measure
of quality of surgical care, the NVASRS had to (1) develop a reliable clinical database of patients relevant preoperative risk factors and postoperative outcomes and
(2) develop analytic tools for proper risk adjustment and
to account for random events (Figure 1). The NVASRS
recognized that surgical care was ideally suited for the
use of outcome rather than process measures in the comparative assessment of quality of care, because surgical
care revolved primarily around a single event (the operation), which, in most cases, had an expected measurable outcome.7
The Outcome of the NVASRS
Based on data from 117 000 major operations collected
prospectively by a dedicated nurse in each of 44 VA medical centers, the NVASRS developed predictive risk adjustment models for 30-day mortality and morbidity in
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21

Table 1. National Veterans Affairs Surgical Risk Study


Expert Advisory Panel (1991-1994)
Surgeons
J. Bradley Aust, MD, San Antonio, Tex
Paul Ebert, MD, Chicago, Ill
John Mannick, MD, Boston, Mass
Health services researchers
Liza Iezzoni, PhD, Boston
Barbara J. McNeil, MD, PhD, Boston
Epidemiologists and statisticians
L. Richard Smith, MD, Durham, NC
J. William Thomas, PhD, Ann Arbor, Mich

Patient Factors

+
Effectiveness of Care
Reliable
Clinical
Database

Valid
Analytic
Models

Random Variation

=
Outcome

Figure 1. The National Surgical Quality Improvement Program (NSQIP) is


based on the assumption, forwarded by Iezzoni,6 that outcomes in surgery
are determined by the sum of patients risk factors, effectiveness or quality
of care, and random variation. By providing a database to account for
patients risk factors and outcomes, and analytic tools for risk adjustment
and to account for random variation, the NSQIP is able to equate the
measurement of outcome with the measurement of quality of care. Adapted
with permission from Mosby Inc.7

9 surgical specialties.4,5 An important and unique component of the NVASRS was a validation study that demonstrated that the risk-adjusted outcomes (30-day mortality and 30-day morbidity) generated from these models
were indicative of the quality of structures and processes in VA medical centers.8 A method was therefore
provided, for the first time, that allowed for the comparative assessment of the quality of surgical care in 9
surgical specialties in the VA. The demonstration of the
feasibility and validity of these methods prompted the
VA to establish in 1994 an ongoing NSQIP for monitoring and improving the quality of surgical care in all VA
medical centers that performed major surgery.2
MATERIALS AND METHODS
Data Acquisition and Transmission
At each VA medical center that performs major surgery,
a clinical surgical nurse reviewer oversees the prospective collection of preoperative, intraoperative, and 30day outcome data on all major operations into a special
module of the VAs electronic clinical record (Table 2).
In some high-volume hospitals, data collection is limited to the first 36 major operations in an 8-day cycle,
with each cycle starting on a different day of the week to
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Table 2. Elements in the National Surgical Quality


Improvement Program Database
Preoperative data
10 Demographic variables
30 Clinical variables
12 Laboratory variables
Intraoperative data
15 Clinical variables
Postoperative data
10 Laboratory variables
30-Day postoperative mortality
21 Categories of 30-day postoperative morbidity
Length of hospital stay

Table 3. National Surgical Quality Improvement Program


Database as of September 30, 2000*

Subspecialty
General
Orthopedics
Urology
Vascular
Cardiac surgery
Neurosurgery
Otolaryngology
Thoracic
Plastic
Other
Total

FY
1998

FY
1999

FY
2000

Total, All
Phases

31 437
20 286
13 251
10 281
7481
5922
5483
3725
2210
2797
102 873

32 163
20 531
13 729
10 753
7214
5943
5193
3560
2246
2921
104 253

31 201
20 524
13 133
9905
8281
5549
3900
3419
2162
2366
100 440

199 519
138 470
99 507
75 963
67 519
44 066
37 743
27 836
17 257
19 567
727 447

27.4
19.0
13.7
10.4
9.3
6.1
5.2
3.8
2.4
2.7
100

*Data are given as number of operations unless otherwise indicated.


FY indicates fiscal year.

produce a representative sample. About 115000 cases are


accrued annually. By the end of fiscal year 2000, the
NSQIP database contained 727 447 complete operations in 9 major specialties (Table 3). Forty-five days
after surgery, data are transmitted to 1 of 2 data coordinating centers. The noncardiac surgery data are transmitted to the Hines VA Cooperative Studies Program Coordinating Center, and the cardiac surgery data are
transmitted to the Center for Continuous Improvement
in Cardiac Surgery at the Denver VA Medical Center, Denver, Colo. At the coordinating center, the data are passed
through an editing program. Potential errors in the data
are transmitted back to the participating sites via query
reports for resolution. Annually, the NSQIP data are passed
through the VAs Beneficiary Identification and Records
Locator Subsystem, an administrative database of all veterans benefits, which includes survival information. The
database, used by the NSQIP for the assertion of interrater reliability, is more than 95% complete with regard
to a veterans vital status.
Predictive Modeling and Risk Adjustment
Annually, the noncardiac surgery data are subjected to
logistic regression analysis to identify the independent
predictors of 30-day mortality, 30-day morbidity, and postoperative length of hospital stay. Separate models are created for all operations and for each of the 8 noncardiac
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22

surgical specialties. These models are predictive, with high


C indexes.4,5 Table 4 lists, in order of decreasing importance, the top 8 variables predictive of 30-day mortality for all operations, as they were calculated over time.
The rank order of these variables did not change much
over time, with the preoperative serum albumin, the
American Society of Anesthesiologists class, and the presence of disseminated cancer remaining as the most important risk factors throughout. The coefficient generated by the model for each predictive variable allows
for the calculation of a population-specific expected outcome that reflects the severity of illness of that population. The risk-adjusted outcome for that specific population is expressed as the O/E ratio, where O represents
the total number of observed events (deaths or complications) and E, the number of events that is expected on
the basis of the compendium of the preoperative risk factors prevalent in that population. Figure 2 shows the
O/E ratio and the 90% confidence interval for the 30day mortality of all noncardiac operations at each hospital participating in the NSQIP in fiscal year 2000. Statistically significant high outlier hospitals, ie, hospitals
in which the confidence interval is above 1.0, are indicated by an asterisk; statistically significant low outlier
hospitals, ie, hospitals in which the confidence interval
is below 1.0, are indicated by a dagger. High outlier hospitals have mortality rates that are significantly higher
than what is expected based on the severity of illness of
their respective patient populations, while low outlier hospitals have mortality rates that are significantly lower than
what is expected based on the severity of the patients
preoperative risk factors. The validation study, which was
conducted as part of the NVASRS, has validated the concept that high outlier hospitals are more likely to have
inferior structures and processes of care, and that low outlier hospitals are more likely to have superior structures
and processes.5,9,10
Feedback to Providers and Managers
The quality improvement function of the NSQIP is effected primarily through feedback of information to the
providers and managers in the field. The various formats of this feedback include the following.
(1) A comprehensive chief of surgery annual report that is specifically prepared for each surgical center. The report contains the risk-adjusted outcomes of
all the participating hospitals, but the identities of these
hospitals are blinded by a code that is changed annually. Each surgical center is privy only to its own hospital code. Site and specialty-specific data are provided that
enable each center to compare the preoperative risk profiles and the outcomes of its patients with those of other
peer hospitals and with national averages.
(2) Periodic assessment of the performance of high
and low outlier institutions. This assessment is performed annually by the executive committee at a 2-day
meeting in which the performance of each of the participating hospitals during a 4-year period is reviewed. The
executive committee communicates to the field certain
levels of concern about the high outlier status of various
surgical centers and subspecialties within these centers.
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Table 4. Order of Entry for the Most Predictive Preoperative Risk Factors of 30-Day Postoperative Morbidity (All Operations Models)*
Risk Factor
Serum albumin, g/dL
American Society of Anesthesiologists class
Disseminated cancer
Emergency operation
Age
Serum urea nitrogen 40 mg/dL (14.3 mmol/L)
Do not resuscitate
Complexity score
Aspartate aminotransferase 40 U/L
Weight loss 10%
Functional status
White blood cell count 11.0 10 3/L

Phase 1

Phase 2

FY 1996

FY 1997

FY 1998

FY 1999

Mean Rank

1
2
3
4
5
6
7
12
11
9
24
16

1
2
3
4
5
7
10
9
8
13
6
14

1
2
3
5
4
6
8
10
9
14
11
15

1
2
3
5
6
9
4
13
17
10
8
11

1
2
3
5
4
12
11
14
28
7
6
9

1
2
3
7
4
5
10
14
13
8
6
11

1.0
2.0
3.0
5.0
4.7
7.5
8.3
12.0
14.3
10.2
10.2
12.7

*C index for all operations models = 0.89 0.91. FY indicates fiscal year.

5.0

4.0

O/E Ratio

3.0

2.0

1.0

0.0

38
95
32
25
133
96
83
141
19
58
109
132
18
143
14
45
44
71
124
26
111
145
126
160
66
20
30
122
59
106
68
49
110
77
99
72
74
142
64
85
55
103
81
40
104
148
9
24
34
33
107
21
84
117
50
11
63
87
27
147
97
31
47
130
75
82
86
98
136
46
4
61
125
52
91
157
17
22
121
93
89
36
120
154
6
113
150
3
105
29
15
151
155
12
94
23
137
128
54
57
35
116
149
139
146
100
159
138
67
152
51
101
79
53
131
7
41
112
140
123
129
80
43
76
156
10
90
39
69
118
28
56
8
37
73
92
60
2
127
1

Veterans Affairs Medical Center

Figure 2. Bar graphs with 90% confidence intervals of the O/E ratios (where O represents the total number of observed events [deaths or complications] and E,
the number of events that is expected on the basis of the compendium of the preoperative risk factors prevalent in that population) for 30-day mortality after all
major operations in the hospitals participating in the National Surgical Quality Improvement Program in fiscal year 2000. Statistically significant low outlier
hospitals are indicated by a dagger and statistically significant high outlier hospitals by an asterisk. The identity of each hospital is concealed by a code known only
to the managers and providers at that hospital. The coding system is changed annually.

The committee also communicates praise and provides


certificates of commendation to centers and surgical
specialties within these centers that demonstrate
improved or superior performance, as evidenced by low
O/E ratios.
(3) Provision of self-assessment tools. The NSQIP
has developed instruments that it has made available to
providers and managers to help them assess the strengths
and weaknesses of their respective programs, particularly when the NSQIP reports show these programs to
be high outliers in their respective risk-adjusted 30-day
mortality or morbidity rates.
(4) Structured site visits for the assessment of data
quality and specific performance. Providers and managers who face potential problems with the outcomes of their
respective surgical services have the option to invite the
NSQIP to conduct structured site visits to help identify
and address deficiencies in the quality of care delivered
by these services. These site visits are conducted in 2
stages. In the first stage, experienced NSQIP nurses conduct a thorough audit to assess the reliability of the data

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23

collection at the site. If no problems with the data are


identified, a second site visit is conducted by a team composed of an experienced surgeon (who usually heads the
team), a health services specialist, an anesthesiologist, and
a critical care nurse. The site visit teams are only consultative to the providers and managers. After the site visit,
the team issues a confidential detailed report of its findings and recommendations, which is distributed to the
senior management and the surgery leadership at the site
of the visit.
(5) Identification and dissemination of best practices. Hospitals that have significantly reduced their O/E
ratios, and hospitals that have maintained consistently
significantly low O/E ratios, are encouraged to report back
to the NSQIP the methods and procedures that they have
used to improve or sustain good risk-adjusted outcomes. The feedback from these hospitals, along with relevant knowledge gained from specific NSQIP site visits
and from investigations conducted on the NSQIP database, are published regularly in the NSQIPs annual report to the hospitals. Dissemination of good practices

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in this manner is a critical component of the quality improvement initiatives of the NSQIP.

groups that are querying the database about hypotheses


related to different surgical issues and conditions.

Investigations Using the Database

THE ESSENTIALS

Using policies modeled after those of the VA Cooperative Studies Program, the NSQIP has established an infrastructure that allows VA surgeons and researchers to
query the database through hypothesis-driven proposals that are submitted to and peer reviewed by the executive committee. Once a study is approved by the NSQIP
executive committee and the investigators local institutional review board, a statistician from the NSQIP Data
Coordinating Center at Hines VA Cooperative Studies Program Coordinating Center is assigned to it, and the data
are analyzed either at the Data Coordinating Center or
at the respective principal investigators facility. The executive committee monitors the scientific quality and integrity of these studies and must review and approve all
scientific presentations and publications that emanate
from these studies before submission. The NSQIP publications to date have included 28 papers published in
peer-reviewed journals,2-5,8-29 24 papers in preparation for
publication in peer-reviewed journals, and 11 invited publications and book chapters.7,30-40 There are 59 research

Quality Improvement

RiskAdjusted
Outcomes

NSQIP

The NSQIP is first and foremost a quality improvement


program (Figure 3). The validity of its outcome-based
methods in assessing the quality of surgical care has been
established. However, the NSQIP is not a punitive program for the purpose of identifying bad apples. On the
contrary, its primary focus is to provide the surgeons and
managers in the field with reliable information, benchmarks, and consultative advice that will guide them in
assessing and continually improving their local processes and structures of care. Chiefs of surgery in the VA
have come to find value in the program and have learned
to use the data and information contained in the annual
report to identify and improve deficiencies that otherwise would have remained unnoticed.41 They have benefited from the various site visits that the NSQIP has organized, and from learning how other colleagues have
addressed specific problems through the section of the
annual report that is dedicated to the dissemination of
best practices. Since the inception of the NSQIP data collection in 1991, the 30-day mortality of major surgery
in the VA has decreased by 27% and the 30-day morbidity has decreased by 45% (Figure 4). The value that VA
surgeons find in the NSQIP is the biggest asset of the program and the only guarantee of its continued effectiveness.

Feedback

Reliable Data
Surgical
Service

Data

The bases for any successful quality improvement process are reliable data. Driving the NSQIP is a compulsion for assurance of data reliability. Only data that could
be reliably collected in pilot studies were incorporated
into the data collection instruments. The data collection process in each hospital is attended to by a nurse
reviewer, capable of making clinical judgments about definitions and outcomes. Nurses are trained on a uniform
set of definitions that is continually improved to eliminate ambiguity and confusion. Interrater reliability and

QI

Figure 3. The Veterans Affairs National Surgical Quality Improvement


Program (NSQIP) collects data from each of its participating sites, ascertains
their cleanliness and reliability, and processes them into comparative
risk-adjusted outcomes. These outcomes, along with other information and
tools, are continuously fed back to the participating centers for the primary
purpose of achieving quality improvement (QI). Adapted with permission
from Mosby Inc.7
3.2

18

16

30-Day Morbidity, %

30-Day Mortality, %

3.0
2.8
2.6
2.4

14

12

10

2.2

B
8

2.0
Phase 1

Phase 2

FY 1996

FY 1997

FY 1998

FY 1999

FY 2000

Phase 1

Phase 2

FY 1996

FY 1997

FY 1998

FY 1999

FY 2000

Figure 4. The 30-day postoperative mortality (A) and 30-day postoperative morbidity (B) for all major operations performed in the Department of Veterans Affairs
hospitals throughout the duration of the National Surgical Quality Improvement Program data collection process. A 27% decrease in the mortality and a 45%
decrease in the morbidity were observed in the face of no change in the patients risk profiles. FY indicates fiscal year.

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core competencies are assessed annually at a nurse reviewers national meeting. The nurse reviewers share their
questions and concerns with regional and national nurse
coordinators through periodic communication, including monthly conference calls. The robustness of the
Veterans Health Information Systems and Technology
Architecture, the VAs electronic medical record infrastructure, allows for electronic assessment of interrater
reliability and for direct transmission of the laboratory
data from the respective medical center laboratory to the
coordinating center at Hines, thereby saving the nurse
reviewer time and improving the accuracy of the data collection process.
As part of ascertaining the reliability of the data in
the development of outcome-based risk adjustment models, the NVASRS had to develop and validate certain quantitative scores, most important of which were a complexity score and a morbidity score. Panels of specialists in 8
surgical specialties were assembled to devise, using a common set of guidelines, a technical complexity score for
each of the more than 3500 Current Procedural Terminology codes in the database. Several scores were also developed to provide a measure of morbidity and were compared with each other. The morbidity score that was
decided on, a dichotomous variable based on the presence or absence of 1 or more complications, was chosen
because of its simplicity, ease of use, and the good correlation it exhibited with the other scores.
The NSQIP assigns high and low outlier status to
specific surgical services and divisions, based on riskadjusted outcomes. As such, it provides a statement on
the quality of care provided by these surgical groups.
Proper risk adjustment is crucial if hospitals or services
are to be singled out as high or low outliers. In the absence of proper risk adjustment, a 60% error rate can be
encountered in assigning an outlier status to a specific
hospital or surgical service.17 Therefore, data reliability,
combined with valid risk-adjustment models, is imperative to a proper comparative assessment of the quality of
surgical care between various institutions.
Setting Standards of Surgical Care
The NSQIP database provides the basis for evidencebased policies and standards of care in surgery. For example, one of the cost cutting measures that was contemplated by VA managers in the mid 1990s was the
closure of surgical services that performed a low volume of major surgery, on the assumption that surgical
outcomes in low-volume hospitals were not as good as
outcomes in high-volume hospitals. An NSQIP study was
conducted to address this issue. It found no relationship in the VA between volume and risk-adjusted outcome of surgery in 8 major common operations.17 The
study confirmed that the volume of surgery in the VA
could not be used as a surrogate for quality and found
no merit in setting up VA standards or policies that are
based on volume of surgery alone. The relationship between volume and outcome of surgery is the subject of a
national debate that has been fueled by the Leapfrog Group
of employers attempt to set standards of care that are based
in part on the volume of surgery performed per surgical
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25

center.17 In the absence of a national database similar to


that of the VAs NSQIP, it will be difficult for the surgical community to reach evidence-based consensus on standards, policies, and performance measures.17
Emphasis on Systems, Not Providers
The compendium of studies and site visits performed by
the NSQIP to date have underscored the fact that quality of surgical care is primarily a function of wellcoordinated systems of care. The identification of breakdowns in systems of care and the attempts to restore and
improve these systems are the bases for the quality improvement initiative in the NSQIP. Single providers of
care, such as the attending surgeon, contribute to the quality of the systems at their respective institutions, but their
role in determining the overall quality of these systems
is just one of many determinants of quality on the surgical service.9,10 Therefore, in the NSQIP, more emphasis is made on the system than on the provider, and provider-specific data are not transmitted to the central
database. There are several reasons why the NSQIP discourages uploading provider-specific information into its
national database. The first is purely statistical; the average surgeon does not perform enough major operations annually to provide a sample size adequate for statistical analysis. The second and more important reason
is that one cannot separate the outcome-based quality of
care rendered by a specific surgeon from that of the outcome-based quality of care rendered by his or her institution. If systems of care are poor at a specific institution, even the most competent surgeon can have poor
outcomes. Likewise, a mediocre surgeon can have excellent outcomes if he or she is functioning in an environment with excellent systems of care. Last, and most
important, surgeons need to buy into the NSQIP if it is
to achieve success in its primary mission of improving
the quality of surgical care. Directing the national focus
to the comparative performance of individual surgeons is sure to alienate the most important constituency of the NSQIP, a lesson learned more than a decade
ago when the comparative outcomes of cardiac surgeons in the state of New York were publicized on the
pages of local and national newspapers.
THE FUTURE
Applicability to the Private Sector
Is the VA NSQIP applicable outside the VA? Three reasons prompted the NSQIP to address this question in
1999. (1) Several non-VA academic surgical centers, which
came to know about the NSQIP through their respective affiliations with VA hospitals, expressed interest in
joining the NSQIP if the option were made available to
them. (2) Making the NSQIP available to the private sector would satisfy, for the first time, the congressional mandate that the VA compare its risk-adjusted surgical outcomes with those of the private sector. (3) The VA
leadership and the NSQIP executive committee were eager to share with the rest of the surgical community the
value that they recognized in the NSQIP as a repository
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QI

QI

Cost

y
rbidit
Mo

Outcome

it y
rbid
Mo

Mortali
ty

Fu

nc

ti o

n al

Outcome

Mortal
it y

Process and
Structure
Q ua
lit y o f L i f e
tio n
S tatu s
t i sf a c
P a ti e nt Sa

Today

Tomorrow

Figure 5. A, Today, the National Surgical Quality Improvement Program is


achieving quality improvement (QI) through measurement and feedback to
providers of risk-adjusted mortality and morbidity. B, The vision for
tomorrow is to achieve more comprehensive quality assessment and
improvement by incorporating additional measures of outcome, measures of
outcome-related structures and processes of care, and measures of
cost-efficiency that are defined in terms of the relationship between cost and
outcome of care.

of information and a tool for quality improvement. Therefore, a private sector initiative was started in 1999 with
the aim of answering 2 specific questions. (1) Are the data
collection and transmission methods used by the VA
NSQIP applicable to non-VA hospitals? (2) Are the models predictive of surgical outcomes of VA patients, developed by the NSQIP, applicable to non-VA patient populations? Three non-VA medical centers participated in
the private sector initiative: the University of Michigan
Medical Center, Ann Arbor; Emory University Hospital,
Atlanta, Ga; and University of Kentucky Chandler Medical Center, Lexington. Using processes and definitions
used by the VA NSQIP, a trained nurse in each of these
3 medical centers collected data on all major general and
vascular operations and entered them into a specially developed secure Internet Web site. The data were then automatically transmitted to the NSQIP Data Coordinating Center at Hines, where they were edited for outlying
or inconsistent values and analyzed. Analysis of the results of the private sector initiative after the first year of
complete data collection showed that the VA NSQIP data
collection and transmission methods were applicable to
all 3 non-VA sites. The predictive and risk adjustment
models were also equally applicable to the VA and the
non-VA populations. These preliminary observations were
encouraging enough for the VA leadership and the NSQIP
executive committee to incorporate into the future plans
of the NSQIP the efforts to make this program available
to the surgical community nationwide.
The Big Picture
Although the NSQIP has achieved a good measure of success in its efforts to use outcomes as a means for measuring and improving the quality of surgical care in the VA,
the NSQIP is still a long way from realizing the vision conceived by its founders. In its efforts to achieve quality improvement, the NSQIP today uses 2 measurable outcomes of surgery: postoperative mortality and postoperative
morbidity (Figure 5A). There are other dimensions of surgical outcome that could be incorporated into the NSQIP
to more thoroughly assess the quality of surgical care. The
most important of these are long-term survival, functional outcomes, quality of life, and patients satisfaction.
Efforts have already begun in the NSQIP to evaluate avail(REPRINTED) ARCH SURG/ VOL 137, JAN 2002
26

able tools for the assessment of these outcomes, and to develop and validate new tools for analyses in which current
tools are inadequate. More important, the NSQIP does not
plan to limit its measures of quality to measures of outcome alone. It is important that process measures also be
incorporated into the assessment of the quality of surgical
care. However, only process measures that are demonstrated to affect outcome should be used for this purpose.
Therefore, an important goal for the NSQIP is the identification of process measures in surgery that directly affect
outcome, and the validation of these measures as tools in
the assessment of the quality of surgical care. Cost is another dimension of health care that cannot be ignored in
the assessment of the overall quality of care. Although cost
can be regarded as an important outcome of health care, it
is the relationship of cost to outcome that defines quality
in surgery. The NSQIP is in a unique position to develop
tools for the assessment of cost-effectiveness, the lowest cost
for the best outcome. The use of process and cost measures in the assessment of the quality of health care also
requires proper risk adjustment, a unique feature of the
NSQIP. Hence, the vision for the NSQIP of tomorrow is a
program that accurately quantifies patients risk and achieves
continuous quality improvement through the proper assessment of risk-adjusted outcomes, outcome-related structures and processes, and outcome-related costs (Figure 5B).
We acknowledge the continuous efforts of all the participants in the NSQIP, particularly the chiefs of surgery and
the clinical nurse reviewers at each VA medical center. We
also acknowledge the members of the NSQIP executive committee, who provide continuous leadership, guidance, and
vision to the quality improvement initiatives described in this
article. The editorial help of Nancy Healey and her assistance in the preparation of the manuscript are also gratefully acknowledged.
Corresponding author and reprints: Shukri F. Khuri,
MD, Veterans Affairs Boston Healthcare System, 1400 VFW
Parkway, West Roxbury, MA 02132 (e-mail: shukri
.khuri@med.va.gov).
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