Opinion
Editorials represent the opinions of the authors and JAMA and not those of the American Medical Association.
EDITORIAL
Hospital Readmissions Following Surgery Turning Complications Into “Treasures” Lucian L. Leape, MD
The assessment by the Centers for Medicare & Medicaid Services (CMS) of financial penalties against hospitals with excessive readmission rates has been controversial from the outset. CMS does not adjust data for complexity of illness Related article page 483 or low socioeconomic status and thus unfairly penalizes hospitals that care for these types of patients: typically academic medical centers and safety net hospitals.1 Even though the various controversies about this program remain unresolved, CMS has expanded it from 3 medical conditions to include all readmissions. Accordingly, the study by Merkow and colleagues2 in this issue of JAMA is timely and relevant. Using data from patients undergoing surgery at 1 of 346 continuously enrolled US hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) between January 1, 2012, and December 31, 2012, the authors assessed readmission rates and reasons for readmission for all surgical procedures and for 6 representative operations: bariatric procedures, colectomy or proctectomy, hysterectomy, total hip or knee arthroplasty, ventral hernia repair, and lower extremity bypass. Among 498 875 operations during the study period, the overall rate of unplanned readmissions was 5.7%, and these readmissions were primarily attributable to surgical complications—a finding that will not surprise most surgeons. Patient and hospital characteristics and socioeconomic factors have a much smaller role in reasons for readmission for patients undergoing surgery than for patients admitted for medical problems. The extent of harm is sobering. Although many of these complications are expected by surgeons, to a nonmedical observer some of the rates seem substantial: 14.9% of patients undergoing lower extremity bypass surgery required readmission, 36% of them because of surgical site infections (SSIs); 10.9% of patients were readmitted following colectomy/ proctectomy, 26% because of SSIs. These defect rates are far higher than are tolerated in any other industry. The findings reported by Merkow et al are noteworthy because they are derived from analysis of ACS NSQIP data, widely regarded as among the most reliable measures of quality. These results contrast with most readmission studies that rely on administrative data, which are known to have major deficiencies. In addition, the authors make several useful suggestions as to how these findings could be used to reduce readmissions—but an important question is how can the data
be used to reduce the pain and suffering that complications cause for patients? Japanese quality experts call complications “treasures” because their analysis can reveal so many opportunities for improvement. Can analysis of these surgical treasures lead to improvement? In the 15 years since the Institute of Medicine (IOM) report To Err Is Human3 brought national attention to the problem of iatrogenic injury, a great deal has been learned about how to reduce harm from medical treatment. Several lessons stand out. First, systems theory works. The IOM gained insight from other industries that most errors and failures are not caused by individual carelessness but by breakdowns in systems. The IOM report recommended that hospitals stop punishing individuals for errors and find ways to change the systems. The validity of the systems approach has been demonstrated by thousands of hospital teams that have achieved significant reductions in injuries, particularly those caused by medication errors and hospital-acquired infections.4 Despite these successes, because of the large number of complications the extent of preventable harm is still substantial. Second, changing systems is hard work and requires serious commitment. Changing hospital systems is especially difficult because of long-standing traditions and entrenched practices. Successful change requires leadership by those with the will, the determination, and the perseverance to overcome obstacles and motivate colleagues. It requires commitment, which comes from a sense of urgency and a sense of possibility. One way to develop a sense of urgency is to translate rates into numbers—ie, actual patients. For example, in the study by Merkow et al, SSIs accounted for 19.5% of the unplanned readmissions. Even though this only represents 1% of the 498 875 ACS NSQIP patients undergoing surgery in 2012, that 1% equals 5565 patients. Reducing that number by half would reduce pain and suffering for more than 2700 patients. If similar success were achieved nationwide, the total would be many times that. The sense of possibility comes from the successes of those who refuse to accept harm as inevitable. The outstanding example is the elimination of central line–associated bloodstream infections achieved by the Michigan Keystone Project,5 which has been repeated in hundreds of hospitals nationwide. “Getting to zero” is not a fantasy or a slogan but a driving concept. Third, the most powerful methods for reducing harm are feedback, learning from the best, and working in col-
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(Reprinted) JAMA February 3, 2015 Volume 313, Number 5
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Opinion Editorial
laboration. Here ACS NSQIP members have a priceless asset: comparative data. At one of the tail ends of the distribution curves are surgeons with very low complication rates. What do they do differently? The best way to find out is by direct observation. This approach was pioneered by the Northern New England Cardiovascular Group, which substantially lowered mortality rates for c ardiac bypass surgery. 6 In-person visits were key: other surgeons see new actions and processes of care that local surgeons consider routine and may not even think to mention. Collaboration is another powerful method for achieving sustained systems changes. A proven mechanism for this is regional collaboratives, in which teams from multiple institutions focus on a single problem, make improvements, and meet periodically to learn from experts and from each other. Successful collaboratives require leadership, teambuilding skills, and a great deal of work. In a comprehensive study of the Keystone collaborative, Dixon-Woods et al7 found that success in improving the quality of care stemmed from convergence of many factors, including peer pressure from other institutions, chief executive officer commitment, and formation of teams that include physicians, nurses, and hospiARTICLE INFORMATION Author Affiliation: Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts. Corresponding Author: Lucian L. Leape, MD, Department of Health Policy and Management, Harvard School of Public Health, 677 Huntington Ave, Boston, MA 02115 ([email protected]). Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. REFERENCES 1. Joynt KE, Jha AK. A path forward on Medicare readmissions. N Engl J Med. 2013;368(13):1175-1177.
468
tal executives, as well as intensive training in safety science, identifying defects, data collection, and use of teamwork tools. Data submission and benchmarking were required monthly. Leaders made coaching calls every 2 weeks; teams met face to face every 6 months. Training and preparation took 5 months before implementation of interventions. The findings reported by Merkow et al provide an unprecedented opportunity to apply these lessons to make substantial reductions in surgical complications. One lesson is learning from the best. In the most recent ACS NSQIP semiannual report, 13.6% of patients undergoing lower extremity bypass surgery had an SSI, but the rate of SSI varied from 2% to 30%.8 The majority of vascular bypass surgeons could learn a great deal by visiting those surgeons who have low complication rates. Lessons from these exemplars also can serve as the focus of regional collaboratives, with which the ACS NSQIP has had some experience. A serious commitment modeled after the Keystone project could produce substantial improvements in the quality of care. It may take a while to “get to zero,” but 50% reductions in surgical complication rates in the near term clearly seem possible.
2. Merkow RP, Ju MH, Chung JW, et al. Underlying reasons associated with hospital readmission following surgery in the United States. JAMA. doi:10.1001/jama.2014.18614. 3. Kohn KT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 1999. 4. Pronovost PJ, Marsteller JA, Goeschel CA. Preventing bloodstream infections: a measurable national success story in quality improvement. Health Aff (Millwood). 2011;30(4):628-634. 5. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355(26):2725-2732.
Northern New England Cardiovascular Disease Study Group: a regional collaborative effort for continuous quality improvement in cardiovascular disease. Jt Comm J Qual Improv. 1998;24(10):594600. 7. Dixon-Woods M, Bosk CL, Aveling EL, Goeschel CA, Pronovost PJ. Explaining Michigan: developing an ex post theory of a quality improvement program. Milbank Q. 2011;89(2):167-205. 8. American College of Surgeons. ACS NSQIP Semiannual Report. Chicago: American College of Surgeons; July 16, 2014.
6. Malenka DJ, O’Connor GT; The Northern New England Cardiovascular Disease Study Group. The
JAMA February 3, 2015 Volume 313, Number 5 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a J H Quillen College User on 05/31/2015
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Editorials represent the opinions of the authors and JAMA and not those of the American Medical Association.
EDITORIAL
Hospital Readmissions Following Surgery Turning Complications Into “Treasures” Lucian L. Leape, MD
The assessment by the Centers for Medicare & Medicaid Services (CMS) of financial penalties against hospitals with excessive readmission rates has been controversial from the outset. CMS does not adjust data for complexity of illness Related article page 483 or low socioeconomic status and thus unfairly penalizes hospitals that care for these types of patients: typically academic medical centers and safety net hospitals.1 Even though the various controversies about this program remain unresolved, CMS has expanded it from 3 medical conditions to include all readmissions. Accordingly, the study by Merkow and colleagues2 in this issue of JAMA is timely and relevant. Using data from patients undergoing surgery at 1 of 346 continuously enrolled US hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) between January 1, 2012, and December 31, 2012, the authors assessed readmission rates and reasons for readmission for all surgical procedures and for 6 representative operations: bariatric procedures, colectomy or proctectomy, hysterectomy, total hip or knee arthroplasty, ventral hernia repair, and lower extremity bypass. Among 498 875 operations during the study period, the overall rate of unplanned readmissions was 5.7%, and these readmissions were primarily attributable to surgical complications—a finding that will not surprise most surgeons. Patient and hospital characteristics and socioeconomic factors have a much smaller role in reasons for readmission for patients undergoing surgery than for patients admitted for medical problems. The extent of harm is sobering. Although many of these complications are expected by surgeons, to a nonmedical observer some of the rates seem substantial: 14.9% of patients undergoing lower extremity bypass surgery required readmission, 36% of them because of surgical site infections (SSIs); 10.9% of patients were readmitted following colectomy/ proctectomy, 26% because of SSIs. These defect rates are far higher than are tolerated in any other industry. The findings reported by Merkow et al are noteworthy because they are derived from analysis of ACS NSQIP data, widely regarded as among the most reliable measures of quality. These results contrast with most readmission studies that rely on administrative data, which are known to have major deficiencies. In addition, the authors make several useful suggestions as to how these findings could be used to reduce readmissions—but an important question is how can the data
be used to reduce the pain and suffering that complications cause for patients? Japanese quality experts call complications “treasures” because their analysis can reveal so many opportunities for improvement. Can analysis of these surgical treasures lead to improvement? In the 15 years since the Institute of Medicine (IOM) report To Err Is Human3 brought national attention to the problem of iatrogenic injury, a great deal has been learned about how to reduce harm from medical treatment. Several lessons stand out. First, systems theory works. The IOM gained insight from other industries that most errors and failures are not caused by individual carelessness but by breakdowns in systems. The IOM report recommended that hospitals stop punishing individuals for errors and find ways to change the systems. The validity of the systems approach has been demonstrated by thousands of hospital teams that have achieved significant reductions in injuries, particularly those caused by medication errors and hospital-acquired infections.4 Despite these successes, because of the large number of complications the extent of preventable harm is still substantial. Second, changing systems is hard work and requires serious commitment. Changing hospital systems is especially difficult because of long-standing traditions and entrenched practices. Successful change requires leadership by those with the will, the determination, and the perseverance to overcome obstacles and motivate colleagues. It requires commitment, which comes from a sense of urgency and a sense of possibility. One way to develop a sense of urgency is to translate rates into numbers—ie, actual patients. For example, in the study by Merkow et al, SSIs accounted for 19.5% of the unplanned readmissions. Even though this only represents 1% of the 498 875 ACS NSQIP patients undergoing surgery in 2012, that 1% equals 5565 patients. Reducing that number by half would reduce pain and suffering for more than 2700 patients. If similar success were achieved nationwide, the total would be many times that. The sense of possibility comes from the successes of those who refuse to accept harm as inevitable. The outstanding example is the elimination of central line–associated bloodstream infections achieved by the Michigan Keystone Project,5 which has been repeated in hundreds of hospitals nationwide. “Getting to zero” is not a fantasy or a slogan but a driving concept. Third, the most powerful methods for reducing harm are feedback, learning from the best, and working in col-
jama.com
(Reprinted) JAMA February 3, 2015 Volume 313, Number 5
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a J H Quillen College User on 05/31/2015
467
Opinion Editorial
laboration. Here ACS NSQIP members have a priceless asset: comparative data. At one of the tail ends of the distribution curves are surgeons with very low complication rates. What do they do differently? The best way to find out is by direct observation. This approach was pioneered by the Northern New England Cardiovascular Group, which substantially lowered mortality rates for c ardiac bypass surgery. 6 In-person visits were key: other surgeons see new actions and processes of care that local surgeons consider routine and may not even think to mention. Collaboration is another powerful method for achieving sustained systems changes. A proven mechanism for this is regional collaboratives, in which teams from multiple institutions focus on a single problem, make improvements, and meet periodically to learn from experts and from each other. Successful collaboratives require leadership, teambuilding skills, and a great deal of work. In a comprehensive study of the Keystone collaborative, Dixon-Woods et al7 found that success in improving the quality of care stemmed from convergence of many factors, including peer pressure from other institutions, chief executive officer commitment, and formation of teams that include physicians, nurses, and hospiARTICLE INFORMATION Author Affiliation: Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts. Corresponding Author: Lucian L. Leape, MD, Department of Health Policy and Management, Harvard School of Public Health, 677 Huntington Ave, Boston, MA 02115 ([email protected]). Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. REFERENCES 1. Joynt KE, Jha AK. A path forward on Medicare readmissions. N Engl J Med. 2013;368(13):1175-1177.
468
tal executives, as well as intensive training in safety science, identifying defects, data collection, and use of teamwork tools. Data submission and benchmarking were required monthly. Leaders made coaching calls every 2 weeks; teams met face to face every 6 months. Training and preparation took 5 months before implementation of interventions. The findings reported by Merkow et al provide an unprecedented opportunity to apply these lessons to make substantial reductions in surgical complications. One lesson is learning from the best. In the most recent ACS NSQIP semiannual report, 13.6% of patients undergoing lower extremity bypass surgery had an SSI, but the rate of SSI varied from 2% to 30%.8 The majority of vascular bypass surgeons could learn a great deal by visiting those surgeons who have low complication rates. Lessons from these exemplars also can serve as the focus of regional collaboratives, with which the ACS NSQIP has had some experience. A serious commitment modeled after the Keystone project could produce substantial improvements in the quality of care. It may take a while to “get to zero,” but 50% reductions in surgical complication rates in the near term clearly seem possible.
2. Merkow RP, Ju MH, Chung JW, et al. Underlying reasons associated with hospital readmission following surgery in the United States. JAMA. doi:10.1001/jama.2014.18614. 3. Kohn KT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 1999. 4. Pronovost PJ, Marsteller JA, Goeschel CA. Preventing bloodstream infections: a measurable national success story in quality improvement. Health Aff (Millwood). 2011;30(4):628-634. 5. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355(26):2725-2732.
Northern New England Cardiovascular Disease Study Group: a regional collaborative effort for continuous quality improvement in cardiovascular disease. Jt Comm J Qual Improv. 1998;24(10):594600. 7. Dixon-Woods M, Bosk CL, Aveling EL, Goeschel CA, Pronovost PJ. Explaining Michigan: developing an ex post theory of a quality improvement program. Milbank Q. 2011;89(2):167-205. 8. American College of Surgeons. ACS NSQIP Semiannual Report. Chicago: American College of Surgeons; July 16, 2014.
6. Malenka DJ, O’Connor GT; The Northern New England Cardiovascular Disease Study Group. The
JAMA February 3, 2015 Volume 313, Number 5 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a J H Quillen College User on 05/31/2015
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