During the mid to late 1980s, the Department of Veterans Affairs (VA) came under a great deal of public scrutiny over the quality of surgical care in its 133 VA hospitals. At issue were the operative mortality rates in the VA hospitals and the perception in Congress that these rates were significantly above the national (private sector) norm. To address the gap, Congress passed Public Law 99-166 to address the gap, which mandated the VA to report its surgical outcomes annually:
- On a risk-adjusted basis to factor in a patient’s severity of illness; and
- Compare them to national averages.
The only problem was that these “national averages” did not exist.
Surgeons at the VA knew there were no national averages or risk-adjustment models for the various surgical specialties. Looking at their own infrastructure, however, with its advanced information systems and centralized authority and organization of hospitals, they realized they were in a unique position to create these data models.
As a result, the VA embarked upon the National VA Surgical Risk Study (NVASRS) in 44 VA medical centers. The foundation for their work was Lisa Iezzoni’s “algebra of effectiveness,” which states that outcomes of healthcare can be described by this equation:
Patient Factors + Effectiveness of Care + Random Variation = Outcome
For this equation to move from theory to practical application, the VA recognized it needed to build a statistically reliable database of patients’ preoperative risk factors and postoperative outcomes. It also had to create methods for accurate risk adjustment and to account for random events.
During this period, a dedicated nurse in each of the 44 medical centers collected preoperative, intraoperative and 30-day outcome variables on more than 117,000 major operations. Using this data, the NVASRS was able to develop risk models for 30-day mortality and morbidity in nine surgical specialties. Additionally, the VA found that the risk-adjusted outcomes produced by the models matched the quality of systems and processes in the 44 hospitals. This work allowed, for the first time, a comparative measurement of the quality of surgical care in the nine specialties.
The success of the NVASRS study encouraged the VA to establish an ongoing program for monitoring and improving the quality of surgical care across all VA medical centers, and the National Surgical Quality Improvement Program (NSQIP) was born. More than 110,000 major surgical cases have been added to the database each year, creating more than 1 million surgical cases presently in the VA system.
Over time, as the VA focused on outcomes, the outcomes improved. The VA hospitals saw a 47 percent drop in postoperative mortality and a 43 percent drop in morbidity rates from 1991 to 2006.
In 1999, the private sector became interested in NSQIP. Specifically, private sector hospitals wanted to know if the methodology used in VA hospitals was applicable outside the VA. They also wanted to know if the risk-adjustment models would hold true for the more heterogeneous private sector patient populations vs. the more homogenous VA system, whose patient population is predominantly male.
A pilot study, initiated in 1999, determined the feasibility of implementing NSQIP in non-VA hospitals. Surgeons at three nonfederal hospitals (Emory University, the University of Michigan, and the University of Kentucky) volunteered to participate in the pilot and to donate the time of a nurse coordinator to collect data. The pilot study included only general and vascular surgery. The three centers found that after the first complete year of analysis, both the data collection/transmission methods and the predictive and risk-adjustment models of NSQIP were applicable to their non-VA environments.
2001 – Today: American College of Surgeons (ACS)
In 2001, ACS launched a pilot program funded by the Agency for Healthcare Research and Quality (AHRQ) to demonstrate that NSQIP also functioned very well in reducing morbidity and mortality in private sector hospitals. Founded in 1913, ACS aims to improve the care of the surgical patient. This goal has always been the guiding force in ACS activities. The development of a national system to collect and report risk-adjusted event data for surgical services was of great importance to the American College of Surgeons, which represents 77,000 surgeons worldwide.
NSQIP functioned very well in the 18 private sector hospitals that took part in the pilot program, and, in October 2002, the Institute of Medicine named NSQIP the “best in the nation” for measuring and reporting surgical quality and outcomes.
In 2004, ACS began enrolling additional private sector hospitals into ACS NSQIP. ACS NSQIP® became the first nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care across surgical specialties in the private sector. ACS NSQIP is available to all private sector hospitals that meet the minimum participation requirements, complete a hospital agreement and pay an annual fee. Hospitals can benefit from participating in ACS NSQIP for many reasons; most importantly, the program can contribute to the reduction of surgical mortality and morbidity. Today, nine of the top 10 hospitals ranked as America’s Best Hospitals by U.S. News & World Report participate in ACS NSQIP.
As hospitals gain more experience with ACS NSQIP, the program continues to evolve in response to learnings and changes in the health care sector. ACS developed four measures in 2009 in partnership with the Centers for Medicare and Medicaid Services (CMS) with the goal of creating practical outcomes-based measures that would help hospitals achieve significant quality improvements. In 2010, ACS NSQIP rolled out new options tailored to a variety of hospital types and quality improvement focuses. Today ACS NSQIP offers Essentials, Small & Rural, Procedure Targeted, Pediatric, and Measures options. In 2011 and beyond, ACS NSQIP is helping interested hospitals join together in regional and specialty collaboratives.