Quality Measurement and Improvement in Colon and Rectal Surgery

 

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In recent years, surgeons have found themselves increasingly under the microscope with regard to quantifying the delivery of quality care and the maintenance of certain standards of practice. This is certainly true for colon and rectal surgery. Several different quality measurement and improvement programs have been devised and implemented at both the local and national levels. One can hardly pick up a surgical journal each month without finding at least one article based on data from National Surgical Quality Improvement Project (NSQIP) or some other quality improvement program. The spirit of these programs is well intended, but they are not without some controversy, as we question whether or not they have resulted in real change.

The quality improvement programs that currently exist are a confusing alphabet soup: NSQIP, Surgical Care Improvement Project (SCIP), Surgical Clinical Outcomes Assessment Program (SCOAP), Surgical infection Program (SIP), Clinical Outcomes Assessment Program (COAP), and so on. The main goal of all these programs, of course, is improved care and outcomes for patients. This is accomplished in two major ways: (1) data collection and evaluation and (2) the subsequent implementation of change based on the data. I think we would all agree this is a valid and important process, and one in which we all share in the same goal. Yet, what do colon and rectal surgeons really care about when it comes to the issue of tracking outcomes and quality assessment/improvement initiatives? For many, the SCIP probably hits closest to home. SCIP targets metrics such as surgical site infection (SSI) and venous thromboembolism prevention. These problems continue to plague colon and rectal surgery despite our best efforts. However, questions still exist in the literature as to whether adherence to SCIP measures actually improves SSI prevention. Many health care institutions mandate participation in quality measurement programs, and financial consequences exist for noncompliance. What then does the future hold for surgeons where quality measurement is concerned? Will the potential punitive aspects of quality measurement ultimately detract from the improvements we all seek, or will we find a way at the national level to overcome the limitations of quality management systems and realize our goals? These are some of the important concepts tackled by the authors in this issue. By the end of this volume, our hope is that you will have a more thorough understanding of the major issues and current status of quality management in the United States, especially as it pertains to colon and rectal surgery, and what the future may hold for us.

This issue will examine the programs germane to colon and rectal surgeons and the effects they have had, and will continue to have, on our practice. Certainly, these discussions overlap to a small degree, as these programs are in their relative infancy, still evolving with regard to their reach, and focus on many of the same metrics. Yet, each of the authors in this volume has focused on a unique aspect, which we hope will provide you with a complete understanding of how these programs affect our practice.

Andrea Bafford and Jonathon Chun from the University of Maryland will start things off by discussing the history of quality measurement and how these programs have taken root and become so important. Jim Yoo from the University of California, Los Angeles, will then examine the individual programs affecting colon and rectal surgeons and tell us how they actually work. Jennifer Irani from the Brigham and Women's Hospital in Boston will inform us about how widespread participation in quality measurement and improvement actually has become. Do universities and other big academic centers mainly use these programs, or has this become commonplace in the community at large? Next, Karim Alavi from the University of Massachusetts will evaluate the variables commonly measured by quality improvement programs. Do we look at too many variables? What are the best variables to look at? Should the list of variables be as exhaustive as possible, or should they be limited to an important few? Certainly, controversy exists surrounding this issue, so CDR James Duncan and CDR Michael McNally from Walter Reed National Military Medical Center will familiarize us with these controversies. Finally, Maj. Fia Yi, from Nellis Air Force Base, Nevada, will discuss the future direction of quality measurement in the United States. If we believe these programs are having a positive effect, what next? If we believe they are not having any positive effect, or even a negative one, what next?

After reviewing the exhaustive efforts of the authors, the reader should have a more thorough understanding of the issues facing each of us in colon and rectal surgery where quality measurement and improvement is concerned. We should also have a better idea of what the future holds for us, as we all strive to improve outcomes for our patients.

I would like to personally thank each of the authors for taking time away from their busy practices and families to explore the past, present, and future of quality measurement and improvement in colon and rectal surgery. I am grateful for their candor in discussing not only quality improvement's positive effects but also its potential limitations. Finally, I would also like to express my thanks and gratitude to Dr. David Beck for giving me the opportunity to present this volume of Clinics in Colon and Rectal Surgery. I hope the readers will find this as helpful and informative as I have.