Quality Improvement

VA Leads the Way in Reporting Surgical Outcomes

September 7, 2018

Believing that surgical mortality rates in VA hospitals were above the national (private sector) rates, in the mid-1980s Congress passed Public Law 99-166 which mandated that VA report its surgical outcomes on an annual basis. However, in order to report on and improve surgical care, VA first had to measure the quality of that care. In response, VA’s Health Services Research and Development Service (HSR&D), the Office of Quality Management, and Patient Care Services worked collaboratively to develop the National Surgical Quality Improvement Program (NSQIP) – a system for collecting, analyzing, and reporting patient risk factors and post-surgical outcomes. NSQIP is based on 135 variables collected preoperatively and up to 30 days postoperatively, including demographics, surgical profile, and preoperative, intraoperative, and postoperative data.

With the implementation of NSQIP came a steady decrease in both risk-adjusted and actual mortality rates tracked annually in VA. From 1991 through 2001, NSQIP resulted in:

• A decline in post-operative mortality by 27%,
• A decline in post-operative morbidity by 45%,
• A decrease in median post-operative length of hospital stay from 9 to 4 days, and
• Improved patient satisfaction with care.

In addition, the number of Veterans undergoing major surgery who experienced post-operative complications decreased from 18% to 10%.¹

Given these results, in 2001, the American College of Surgeons (ACS) began to take an active interest in the NSQIP and its results in reducing surgical mortality and morbidity rates. In collaboration with VA, the ACS expanded the NSQIP into the private sector. As a result, each participating private sector NSQIP hospital was shown to eliminate an average of 250 postoperative complications and 12 to 27 surgical deaths per year.² In October 2002, this led the Institute of Medicine report “Leadership by Example” to name the NSQIP the “best in the nation” for measuring and reporting surgical quality and outcomes.

In 2009, the Cardiac Specialty program (Continuous Improvement in Cardiac Surgery Program - CICSP) was merged with NSQIP for a comprehensive all-specialty surgical database, VASQIP – the VA Surgical Quality Improvement Program. VASQIP continuously collects clinically rich data from all VA institutions where major surgery is performed, including information on post-operative morbidity and mortality. A recent study used VASQIP data to examine post-operative outcomes for 704,901 Veterans who underwent inpatient general, vascular, thoracic, genitourinary, neurosurgical, orthopedic, or spine surgery from FY2000 through FY2014 at 143 VA hospitals. Over the 15 years of the study, results showed that there have been decreases of 25%, 54%, and 41% in morbidity, mortality, and failure to rescue (respectively), with an ~40%-50% decrease in the odds of post-operative adverse events. Notably, these improvements have occurred VA-wide and not only at the best-performing VA hospitals.³

1. Khuri S, Daley J, and Henderson W. The comparative assessment and improvement of quality of surgical care in the Department of Veterans Affairs. Archives of Surgery. January 2002;137(1):20-27.
2. Hall B, Hamilton B, Richards K, et al. Does surgical quality improve in the American College of Surgeons National Surgical Quality Improvement Program: An evaluation of all participating hospitals. Annals of Surgery. September 2009;250(3):363-376.
3. Massarweh N, Kougias P, and Wilson M. Complications and Failure to Rescue after Inpatient Non-Cardiac Surgery in the Veterans Affairs Health System. JAMA Surgery. December 1, 2016;151(12):1157-11