Tennessee Hospitals Cut Costs While Improving Outcomes

HOT SPRINGS, VA. – A collaboration among 10 hospitals in Tennessee has produced a boost in quality of care while also saving millions of dollars.

The collaboration first got started in 2005, when the three initial participants – Erlanger Medical Center in Chattanooga, Vanderbilt University Medical Center in Nashville, and St. Francis Hospital–Memphis – took inspiration from the rollout of the American College of Surgeons’ National Surgical Quality Improvement Project (NSQIP), said Dr. Joseph B. Cofer, a professor of surgery at the University of Tennessee, Chattanooga.

A successful run so far has led BlueCross Blue Shield of Tennessee (which has bankrolled the operation) to extend its funding through 2012 for the 10 hospitals that are currently participating, said Dr. Cofer. And it made funds available for an additional 11 hospitals to join, which would bring the total to 21.

With data now complete for 2009 and 2010, the Tennessee Surgical Quality Collaborative reported that postoperative mortality was not statistically significantly different from the first year (2.32%, or 232/10,000) to the second year (2.38%, or 237/10,000).

However, significant declines in postoperative complications in five areas – acute renal failure (25% drop), graft/flap failure (60% drop), ventilation for more than 48 hours (15% drop), superficial incisional surgical-site infection (19% drop), and wound disruption (34% drop) – resulted in total savings of $4.47 million.

At the same time, increases in postoperative complications in three areas – urinary tract infection (42% rise), pneumonia (23% rise), and deep vein thrombosis (35% rise) – cost $2.1 million.

Overall, the savings were at least $2 million for the 10 participating hospitals, said Dr. Cofer. But that number reflects only a sampling of cases from the 10 hospitals; if all the cases had been included, "we can reliably say we probably avoided about $8 million in costs over this year," Dr. Cofer said.

"Why this happened, we don’t know," he added. It’s possible that just being part of the NSQIP process improves monitoring and outcomes.

The Tennessee collaborative is now identifying exemplar hospitals and "sending out teams to dissect how they did it so well," Dr. Cofer said. Then, those best practices will be disseminated to other hospitals in the collaborative.

The collaboration would not likely have been possible without the participation of BlueCross BlueShield of Tennessee. Dr. Cofer spearheaded the talks with the insurer, which began in 2006 and culminated in a three-way partnership among the Blues, the Tennessee chapter of the ACS, and the Tennessee Hospital Association. In 2008, the Blues announced that it was giving the collaboration $2.5 million over the next 3 years to fund the collaborative.

Another crucial element was the leadership committee, said Dr. Cofer. Of the seven committee members, four are surgeons, two are hospital CEOs, and one is a staff person from the Tennessee Hospital Association. Data cannot be released without permission of the committee, and, so far, specific data are not being shared.

Dr. J. David Richardson, a discussant and chairman of the NSQIP committee at ACS, said, "it takes a tremendous effort to put a group like this together," adding that "within the ACS, I think we’ve all been heartened by the initiative taken by the Tennessee chapter in developing this program." The ACS is looking to expand the program, particularly beyond Veterans Affairs hospitals, said Dr. Richardson, professor and vice chairman of surgery at the University of Louisville (Ky.). The collaborative model is a way to spread the cost, so it may entice more participants, he said.

"This is a provocative paper because it should provoke us to follow suit," Dr. Joseph J. Tepas III, professor of surgery at the University of Florida, Jacksonville, said in his discussion of the paper. "This report demonstrates that this engine of quality, fueled by real-time clinical data, produces results that are understandable to the nonphysician public."

He added that just participating in NSQIP likely improved the hospitals’ quality. "The power of NSQIP is, first, in its surveillance, and this is what’s so well demonstrated here," he said.

Dr. Tepas, Dr. Richardson, and several other discussants asked why there had been improvement in some clinical areas but not in others. Was this perhaps a change in surgical leadership, or – as Dr. Cofer suggested – the Hawthorne effect (that is, the tendency of outcomes to improve when participants – in this case, hospitals and surgeons – know they are being monitored)?

Lead author Dr. Oscar Guillamondegui had an answer: "There have been no real changes in leadership at any of these hospitals, but if you think about the cost of putting together a NSQIP program – other than for the large hospitals – for many of these hospitals, it’s a bottom-line item that’s not insubstantial," he said. "Most hospitals will push to have improvement of care just based on the fact they’re putting that kind of funding into a system," said Dr. Guillamondegui of the division of trauma and surgical critical care at Vanderbilt University Medical Center. He also surmised that the Hawthorne effect may have played a part.

Some outcomes got worse, likely because of natural variations, but also because NSQIP definitions are strict and include a 30-day window, he said. For instance, more than half of urinary tract infections happen outside the hospital, but if they occur within 30 days of admission, they fall within the NSQIP 30-day morbidity outcome window.

Going forward, sustaining such collaboratives could be difficult, said Dr. Guillamondegui. "If you have a weak surgeon champion, then the program does nothing," especially if data are not being shared with other surgeons or the hospital administration. "If your culture isn’t capable of sustaining this, it will fail."

Dr. Cofer, Dr. Tepas, and Dr. Guillamondegui reported no conflicts. Dr. Richardson chairs the ACS NSQIP committee.

HOT SPRINGS, VA. – A collaboration among 10 hospitals in Tennessee has produced a boost in quality of care while also saving millions of dollars.

The collaboration first got started in 2005, when the three initial participants – Erlanger Medical Center in Chattanooga, Vanderbilt University Medical Center in Nashville, and St. Francis Hospital–Memphis – took inspiration from the rollout of the American College of Surgeons’ National Surgical Quality Improvement Project (NSQIP), said Dr. Joseph B. Cofer, a professor of surgery at the University of Tennessee, Chattanooga.

A successful run so far has led BlueCross Blue Shield of Tennessee (which has bankrolled the operation) to extend its funding through 2012 for the 10 hospitals that are currently participating, said Dr. Cofer. And it made funds available for an additional 11 hospitals to join, which would bring the total to 21.

With data now complete for 2009 and 2010, the Tennessee Surgical Quality Collaborative reported that postoperative mortality was not statistically significantly different from the first year (2.32%, or 232/10,000) to the second year (2.38%, or 237/10,000).

However, significant declines in postoperative complications in five areas – acute renal failure (25% drop), graft/flap failure (60% drop), ventilation for more than 48 hours (15% drop), superficial incisional surgical-site infection (19% drop), and wound disruption (34% drop) – resulted in total savings of $4.47 million.

At the same time, increases in postoperative complications in three areas – urinary tract infection (42% rise), pneumonia (23% rise), and deep vein thrombosis (35% rise) – cost $2.1 million.

Overall, the savings were at least $2 million for the 10 participating hospitals, said Dr. Cofer. But that number reflects only a sampling of cases from the 10 hospitals; if all the cases had been included, "we can reliably say we probably avoided about $8 million in costs over this year," Dr. Cofer said.

"Why this happened, we don’t know," he added. It’s possible that just being part of the NSQIP process improves monitoring and outcomes.

The Tennessee collaborative is now identifying exemplar hospitals and "sending out teams to dissect how they did it so well," Dr. Cofer said. Then, those best practices will be disseminated to other hospitals in the collaborative.

The collaboration would not likely have been possible without the participation of BlueCross BlueShield of Tennessee. Dr. Cofer spearheaded the talks with the insurer, which began in 2006 and culminated in a three-way partnership among the Blues, the Tennessee chapter of the ACS, and the Tennessee Hospital Association. In 2008, the Blues announced that it was giving the collaboration $2.5 million over the next 3 years to fund the collaborative.

Another crucial element was the leadership committee, said Dr. Cofer. Of the seven committee members, four are surgeons, two are hospital CEOs, and one is a staff person from the Tennessee Hospital Association. Data cannot be released without permission of the committee, and, so far, specific data are not being shared.

Dr. J. David Richardson, a discussant and chairman of the NSQIP committee at ACS, said, "it takes a tremendous effort to put a group like this together," adding that "within the ACS, I think we’ve all been heartened by the initiative taken by the Tennessee chapter in developing this program." The ACS is looking to expand the program, particularly beyond Veterans Affairs hospitals, said Dr. Richardson, professor and vice chairman of surgery at the University of Louisville (Ky.). The collaborative model is a way to spread the cost, so it may entice more participants, he said.

"This is a provocative paper because it should provoke us to follow suit," Dr. Joseph J. Tepas III, professor of surgery at the University of Florida, Jacksonville, said in his discussion of the paper. "This report demonstrates that this engine of quality, fueled by real-time clinical data, produces results that are understandable to the nonphysician public."

He added that just participating in NSQIP likely improved the hospitals’ quality. "The power of NSQIP is, first, in its surveillance, and this is what’s so well demonstrated here," he said.

Dr. Tepas, Dr. Richardson, and several other discussants asked why there had been improvement in some clinical areas but not in others. Was this perhaps a change in surgical leadership, or – as Dr. Cofer suggested – the Hawthorne effect (that is, the tendency of outcomes to improve when participants – in this case, hospitals and surgeons – know they are being monitored)?

Lead author Dr. Oscar Guillamondegui had an answer: "There have been no real changes in leadership at any of these hospitals, but if you think about the cost of putting together a NSQIP program – other than for the large hospitals – for many of these hospitals, it’s a bottom-line item that’s not insubstantial," he said. "Most hospitals will push to have improvement of care just based on the fact they’re putting that kind of funding into a system," said Dr. Guillamondegui of the division of trauma and surgical critical care at Vanderbilt University Medical Center. He also surmised that the Hawthorne effect may have played a part.

Some outcomes got worse, likely because of natural variations, but also because NSQIP definitions are strict and include a 30-day window, he said. For instance, more than half of urinary tract infections happen outside the hospital, but if they occur within 30 days of admission, they fall within the NSQIP 30-day morbidity outcome window.

Going forward, sustaining such collaboratives could be difficult, said Dr. Guillamondegui. "If you have a weak surgeon champion, then the program does nothing," especially if data are not being shared with other surgeons or the hospital administration. "If your culture isn’t capable of sustaining this, it will fail."

Dr. Cofer, Dr. Tepas, and Dr. Guillamondegui reported no conflicts. Dr. Richardson chairs the ACS NSQIP committee.

HOT SPRINGS, VA. – A collaboration among 10 hospitals in Tennessee has produced a boost in quality of care while also saving millions of dollars.

The collaboration first got started in 2005, when the three initial participants – Erlanger Medical Center in Chattanooga, Vanderbilt University Medical Center in Nashville, and St. Francis Hospital–Memphis – took inspiration from the rollout of the American College of Surgeons’ National Surgical Quality Improvement Project (NSQIP), said Dr. Joseph B. Cofer, a professor of surgery at the University of Tennessee, Chattanooga.

A successful run so far has led BlueCross Blue Shield of Tennessee (which has bankrolled the operation) to extend its funding through 2012 for the 10 hospitals that are currently participating, said Dr. Cofer. And it made funds available for an additional 11 hospitals to join, which would bring the total to 21.

With data now complete for 2009 and 2010, the Tennessee Surgical Quality Collaborative reported that postoperative mortality was not statistically significantly different from the first year (2.32%, or 232/10,000) to the second year (2.38%, or 237/10,000).

However, significant declines in postoperative complications in five areas – acute renal failure (25% drop), graft/flap failure (60% drop), ventilation for more than 48 hours (15% drop), superficial incisional surgical-site infection (19% drop), and wound disruption (34% drop) – resulted in total savings of $4.47 million.

At the same time, increases in postoperative complications in three areas – urinary tract infection (42% rise), pneumonia (23% rise), and deep vein thrombosis (35% rise) – cost $2.1 million.

Overall, the savings were at least $2 million for the 10 participating hospitals, said Dr. Cofer. But that number reflects only a sampling of cases from the 10 hospitals; if all the cases had been included, "we can reliably say we probably avoided about $8 million in costs over this year," Dr. Cofer said.

"Why this happened, we don’t know," he added. It’s possible that just being part of the NSQIP process improves monitoring and outcomes.

The Tennessee collaborative is now identifying exemplar hospitals and "sending out teams to dissect how they did it so well," Dr. Cofer said. Then, those best practices will be disseminated to other hospitals in the collaborative.

The collaboration would not likely have been possible without the participation of BlueCross BlueShield of Tennessee. Dr. Cofer spearheaded the talks with the insurer, which began in 2006 and culminated in a three-way partnership among the Blues, the Tennessee chapter of the ACS, and the Tennessee Hospital Association. In 2008, the Blues announced that it was giving the collaboration $2.5 million over the next 3 years to fund the collaborative.

Another crucial element was the leadership committee, said Dr. Cofer. Of the seven committee members, four are surgeons, two are hospital CEOs, and one is a staff person from the Tennessee Hospital Association. Data cannot be released without permission of the committee, and, so far, specific data are not being shared.

Dr. J. David Richardson, a discussant and chairman of the NSQIP committee at ACS, said, "it takes a tremendous effort to put a group like this together," adding that "within the ACS, I think we’ve all been heartened by the initiative taken by the Tennessee chapter in developing this program." The ACS is looking to expand the program, particularly beyond Veterans Affairs hospitals, said Dr. Richardson, professor and vice chairman of surgery at the University of Louisville (Ky.). The collaborative model is a way to spread the cost, so it may entice more participants, he said.

"This is a provocative paper because it should provoke us to follow suit," Dr. Joseph J. Tepas III, professor of surgery at the University of Florida, Jacksonville, said in his discussion of the paper. "This report demonstrates that this engine of quality, fueled by real-time clinical data, produces results that are understandable to the nonphysician public."

He added that just participating in NSQIP likely improved the hospitals’ quality. "The power of NSQIP is, first, in its surveillance, and this is what’s so well demonstrated here," he said.

Dr. Tepas, Dr. Richardson, and several other discussants asked why there had been improvement in some clinical areas but not in others. Was this perhaps a change in surgical leadership, or – as Dr. Cofer suggested – the Hawthorne effect (that is, the tendency of outcomes to improve when participants – in this case, hospitals and surgeons – know they are being monitored)?

Lead author Dr. Oscar Guillamondegui had an answer: "There have been no real changes in leadership at any of these hospitals, but if you think about the cost of putting together a NSQIP program – other than for the large hospitals – for many of these hospitals, it’s a bottom-line item that’s not insubstantial," he said. "Most hospitals will push to have improvement of care just based on the fact they’re putting that kind of funding into a system," said Dr. Guillamondegui of the division of trauma and surgical critical care at Vanderbilt University Medical Center. He also surmised that the Hawthorne effect may have played a part.

Some outcomes got worse, likely because of natural variations, but also because NSQIP definitions are strict and include a 30-day window, he said. For instance, more than half of urinary tract infections happen outside the hospital, but if they occur within 30 days of admission, they fall within the NSQIP 30-day morbidity outcome window.

Going forward, sustaining such collaboratives could be difficult, said Dr. Guillamondegui. "If you have a weak surgeon champion, then the program does nothing," especially if data are not being shared with other surgeons or the hospital administration. "If your culture isn’t capable of sustaining this, it will fail."

Dr. Cofer, Dr. Tepas, and Dr. Guillamondegui reported no conflicts. Dr. Richardson chairs the ACS NSQIP committee.