Continuous Assessment and Improvement in Quality of Care A Model from the Department of Veterans Affairs Cardiac Surgery

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Abstract
The authors organized the Department of Veterans Affairs (VA) Continuous Improvement in Cardiac Surgery Study (CICSS) to provide risk-adjusted outcome data for the continuous assessment and improvement of quality of care for all patients undergoing cardiac surgery in the VA. The use of risk-adjusted outcomes to monitor quality of health care has the potential advantage over consensus-derived standards of being free of preconceived biases about how health care should be provided. Monitoring outcomes of all health care episodes, as opposed to review of selected cases (e.g., adverse outcomes), has the advantages of greater statistical power, the opportunity to compare processes of care between good and bad outcomes, and the positive psychology of treating all providers equally. These two concepts, together with a pre-existing peer committee (the VA Cardiac Surgery Consultants Committee) to review, interpret, and act on the risk-adjusted outcome data, form the primary design considerations for CICSS. Patient-level risk and outcome (operative mortality and morbidity) data are collected prospectively on each of the approximately 7000 patients undergoing cardiac surgery in the VA each year. These outcomes, adjusted for patient risk using logistic regression, are provided every 6 months to each cardiac surgery program and to a national peer review committee for internal and external quality assessment and improvement. For the most recent 12-month period with complete data collection, observed-to-expected (O/E) ratios ranged from 0.2 to 2.2, with eight centers falling outside of the 90% confidence limits for an O/E ratio equaling 1.0. The O/E ratio for all centers has fallen by 14% over the 4.5-year period of this program (p = 0.06). A large-scale, low-cost program of continuous quality improvement using risk-adjusted outcome is feasible. This program has been associated with a decrease in risk-adjusted operative mortality.