• Keys to Successful Surgical Quality Improvement

    Betty Hintch Jan 31, 2013

    An interview with Scott J. Ellner, DO


    Saint Francis Hospital and Medical Center’s team approach to surgical quality improvement resulted in a 62 percent reduction in catheter-associated urinary tract infections.


    Dr  Ellner speaking photo

    Reducing the number of urinary tract infections (UTIs)—and saving approximately $53,000 in medical costs per patient—is just one example of how Saint Francis Hospital and Medical Center is improving quality and reducing costs.

    Benchmark data from the American College of Surgeon’s National Surgical Quality Improvement Program (ACS NSQIP®) showed that Saint Francis had a higher post-surgical UTI rate than its peers. “When we brought these data to the hospital’s quality committee, we realized that catheter-associated UTIs were a problem throughout the hospital, not just in surgery,” says Scott J. Ellner, DO, MPH, FACS, vice chairman of surgery and director of surgical quality at Saint Francis in Hartford, Conn. “So we got buy-in from all the key stakeholders and leaders and worked together to reduce our UTI rate.”

    One key change was to encourage the prompt removal of urinary catheters within two days of surgery, which is recognized standard of care. A standing protocol was put in place that allows nurses to remove catheters from patients meeting specific criteria without a physician’s permission. “We knew what the problem was,” says Ellner who is also a practicing general surgeon. “It was just getting everyone on the same page.” As a result of the team effort, the hospital’s rate of catheter-associated UTIs went from 3 percent to 1 percent among all patients.

    When asked what is critical to a successful surgical improvement program, Ellner points to a variety of factors, including trustworthy data and alliances with key stakeholders.

    Start with Reliable Data

    “The best way to get people to buy into a quality improvement program is to share clinical outcomes and data metrics that they will actually believe,” says Ellner. The ACS NSQIP® benchmarking service allows Saint Francis to see how it compares to other hospitals on numerous surgical quality outcomes. “These data are risk-adjusted and based on evidence,” says Ellner. “It is something that you know has been audited and is very accurate.”

    Pinpoint Variation

    Saint Francis focuses surgical improvement efforts on high-risk procedures, such as colon surgery. “There is a lot of variability in colon surgery, and we have benchmark data that helps us demonstrate this,” says Ellner. “We are working with stakeholders to standardize how colon surgery patients are prepared for surgery.”

    For example, Saint Francis now requires that an antibiotic be prescribed to all patients prior to colon surgery. In addition, as part of the preoperative preparation, patients are counseled to stop smoking, start a walking program, and work with a dietitian to improve their nutritional status.

    Steps are also taken during colon surgery to limit infections. For instance, all of the surgeons are provided a new set of gowns, gloves, and sterile instruments toward the end of the surgery before closing the abdomen. This prevents the spread of contamination from the earlier part of the surgery when the colon was handled.

    “As you limit unnecessary variation, you can minimize adverse events,” says Ellner. “After six months of implementing standardized approaches, we are seeing an improvement in our raw data showing a decrease in surgical site infections.”

    Build Key Alliances

    To avoid resistance to a surgical quality program, recruit core supporters on the surgical quality team (including physician and nurse champions), and then reach out to stakeholders who may be resistant to your goals. “Don’t minimize the importance of this step,” says Ellner. “Often, individuals who have the greatest chance of affecting change are the hardest to engage. For example, be mindful of those individuals who are already working on their own quality projects and may be threatened by a competing initiative. You need time to break down barriers to bring them into the fold,” says Ellner.

    Building alliances also requires understanding the needs of hospital staff members who have divergent interests and perspectives. “Tensions can run strong and health care is a high-risk environment. You have to create an environment where you get people to listen actively to each other. One way to do that is through safe conversations, which are discussions designed to ensure that all opinions are considered carefully and treated respectfully,” Ellner says.

    For example, an anesthesiologist and a surgeon, who by nature of their training have different perspectives on the surgical process, may disagree whether a patient should receive local anesthesia or go under general anesthesia. Through safe conversations, these healthcare professionals can come to a consensus that satisfies both of their desires to deliver the best possible care to the patient. (See article sidebar for more ideas on involving physicians in quality improvement.)


    Recognizing everyone’s opinions and perspectives is a practice that is modeled from the top down at Saint Francis. “Our CEO is willing to listen to everyone in our organization, no matter what their role in the delivery of care,” Ellner says.

    Work with Finance

    Ellner also recommends involving finance in clinical improvement initiatives. “Our CFO is very involved in our quality committee, and he has looked at our costs for patients who have suffered adverse events,” says Ellner. “With his assistance, we’ve demonstrated that, when we avoid certain complications, we have shorter lengths of stays or our expenses are more in line with Medicare reimbursement.”

    For example, during its UTI initiative, Saint Francis performed an activity-based cost analysis. The CFO and I reviewed the hospital’s 72 UTI cases over a four-year period. Forty-one of these cases occurred among inpatients and resulted in five deaths and an average additional cost per case of more than $52,000. The 33 outpatient UTIs cost an additional $758 per patient and resulted in two readmissions and four emergency department visits.

    In another example, as part of its goal to improve colon surgery outcomes, St. Francis invited its revenue cycle and supply chain staff members to observe surgeries to better understand the needs of the OR teams and identify opportunities to minimize waste. “I spent time with our CFO analyzing line item costs for several surgical cases,” says Ellner. “It became evident that, by reducing variation in surgery, we could save close to $5,000 per case by switching to less costly instruments and maintaining or improving outcomes. We perform approximately 1,000 colorectal cases annually, so the cost savings is substantial.”

    Bring in Patients

    St. Francis asks patients to provide their perspectives on how the hospital can improve care. This patient may have had a good or bad surgical experience in the hospital. “Either way, a patient will tell you how it really feels to have surgery in your hospital. When you have a patient who can keep you honest, it opens up opportunities that you didn’t see before,” says Ellner. Patient representatives are encouraged to discuss their experiences in private or in groups.

    For example, a guest speaker shared her tragic experience of losing her 15-year-old son after an elective surgery done at another hospital. “She shared her story with St. Francis staff so we could learn from previous mistakes. This was a powerful opportunity to openly discuss medical errors and how to work with our patients to avoid them,” Ellner says.

    Promote Awareness

    By 2015, quality healthcare won’t be an option, says Ellner, because the Centers for Medicare & Medicaid Services’ (CMS’s) rules for value-based health care will be in full swing. “In the future, hospital and health systems will be reimbursed based on quality outcomes,” Ellner says. “Ignoring quality improvement will translate into a loss of revenue from lost Medicare and Medicaid reimbursements.” 

    Betty Hintch is editor, newsletters and forums, at HFMA (bhintch@hfma.org).

    Interviewed for this article:
    Scott J. Ellner, DO, MPH, FACS, vice chairman of surgery and director of surgical quality at Saint Francis Hospital and Medical Center, Hartford, Conn. (sce107@mail.harvard.edu).