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Our Quality Improvement Program

  Soddo Christian Hospital, Ethiopia

Dr. John Sweeney

Led by Dr. John Sweeney, interim chair of the Department of Surgery and chief of the Division of General and Gastrointestinal Surgery, the quality and safety program of the Department of Surgery participates in the University HealthSystem Consortium (UHC), Best Practices for Better Care (BPBC), American College of Surgeons National Surgical Quality Improvement Program (ACS/NSQIP), and the Surgical Care Improvement Project (SCIP). Through these resources, Dr. Sweeney and surgical quality teams throughout the Department develop surgical service-specific quality metrics and checklists, define areas needing improvement, and assist in designing strategies to tackle any shortfalls.

University Healthcare Consortium (UHC)

An alliance of 118 academic medical centers and 299 of their affiliated hospitals, UHC receives billing data and "core measure" quality data from its members. In turn, the consortium allows member hospitals to benchmark with each other by accessing its transparent, web-enabled database, and by reviewing UHC-generated quarterly management reports. Emory joined UHC in 2006.

In 2013 UHC ranked Emory University Hospital (combined with Emory University Orthopaedics & Spine Hospital) 2nd and Emory University Hospital Midtown 3rd in the 2013 UHC Quality Leadership Awards, the second time that Emory Healthcare has had two of its large teaching hospitals rank in the top 10 nationally. Last year, Emory University Hospital ranked 2nd and Emory University Hospital Midtown ranked 6th. Also, Emory Healthcare is again UHC's only health care organization where two hospitals from the same system have ranked in the top 10.

The climb to UHC's top tier has been greatly influenced by the efforts of Dr. Sweeney's teams at these hospitals. UHC's rankings are based on multiple domains of quality: mortality, core measures (process of care), equity of core measures, readmissions, safety, patient centeredness, and efficiency. These rankings are the most rigorous in health care and look at how major teaching hospitals are doing in multiple dimensions of quality and safety, and are traditionally looked upon as providing the best, most non-biased national quality measurement system available for teaching hospitals.

Best Practices for Better Care (BPBC) Surgical Safety Collaborative

In 2012, our quality program joined the BPBC, a surgical safety collaborative and multi-year initiative of the UHC and the Association of American Medical Colleges (AAMC). The BPBC's mission is to expand the use of evidence-based best practices in surgery through cooperation between UHC-member academic medical centers. BPBC's five primary commitment areas include teaching quality and patient safety to the next generation of doctors; ensuring safer surgery through use of surgical checklists; reducing infections from central lines using proven protocols; reducing hospital readmissions for high-risk patients; and researching, evaluating, and sharing new and improved practices.

The Department's quality program and over twenty other academic medical centers—including five in the UHC Top Ten for quality—are collecting data and transmitting it to BPBC for tracking, trending, and reporting. Since our program had already implemented a Surgical Safety Checklist at EUH, we used the rollout of the Surgical Safety Checklist at Emory University Hospital Midtown as our first project for the BPBC. The initiative allowed Midtown's surgical process improvement teams to draw from the experience of physicians across the nation while also sharing Emory's innovations with other peer institutions.

American College of Surgeons National Surgical Quality Improvement Program (ACS/NSQIP)

The ACS/NSQIP employs a prospective, peer reviewed database to quantify 30-day risk-adjusted surgical outcomes that encompass such variables as preoperative risk factors and postoperative mortality and morbidity, allowing comparison of outcomes among all hospitals in the program. Enrolled hospitals abstract case data into the database, the data is quantified, and the database generates comprehensive semiannual reports to the hospitals as well as real-time, continuously updated, online benchmarking reports. Participating programs can then monitor their quality improvement efforts and compare their surgical outcomes—on a blinded basis—with peer hospitals and national averages.

Surgical Care Improvement Project (SCIP)

SCIP is a national quality partnership of organizations focused on improving surgical care by significantly reducing surgical complications. Such a reduction requires that surgeons, anesthesiologists, preoperative nurses, pharmacists, infection control professionals, and hospital executives work together to make surgical care improvement a priority. SCIP has developed quality indicators/measures based on scientific evidence that can reflect guidelines, standards of care, or practice parameters for its partner hospitals. Measures include recommended catheter removal; appropriate hair removal from surgical sites; the timing, dosage, and duration of antibiotics; blood glucose control; and maintaining normothermia.

By converting medical information from patient records into rates or percentages for comparison to the quality indicators/measures, partner hospitals can evaluate their care alongside state and national benchmarks and identify those areas needing improvement. Since the Department of Surgery joined SCIP in 2009, Emory University Hospital has gradually risen in compliance levels.

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