Defining, Tracking, and Delivering Excellence in Surgical Care

Background

What is SCOAP?

SCOAP, the Surgical Care and Outcomes Assessment Program, is a Washington State-wide quality improvement program whose goal is to improve the care and outcomes of people undergoing a general surgical procedure. It focuses on what can be changed: actionable process measures. This recognizes both the system level components of good outcomes across surgical procedures and the need for long-term surveillance of outcomes. SCOAP is a QI program, not a data registry or accreditation program, and will be the backbone for tracking of all statewide major surgical procedures rather than a program in response to concerns for any one particular surgical procedure. As a Coordinated Quality Improvement Program approved by the Washington State Department of Health, SCOAP QI data are protected from disclosure.

How did SCOAP originate?

SCOAP is an extension of the cardiac Clinical Outcomes Assessment Program (COAP), a statewide QI program in which all Washington hospitals that perform cardiac procedures (coronary artery bypass grafts, percutaneous coronary interventions, and valve procedures) participate.

Based on the success of COAP in improving key cardiac process and outcomes measures, in 2003 the Washington State Health Care Authority funded a study to assess the feasibility of expanding the COAP processes and principles to procedures performed by general surgeons. The study, carried out by the University of Washington and the Foundation for Health Care Quality, identified significant opportunities to decrease variation in processes and outcomes in Washington for many general surgical procedures. For example, the rate of negative appendectomy is 15% (25% for women) and the use of CT scanning in appendectomy ranges from 10-90%; for bariatric (weight-loss) procedures, 30-day mortality ranges from 1-8%; in colectomy and proctectomy cases, the range of in-hospital and 30-day reinterventions is 1-10%. Other surgical procedures, e.g., cholecystectomy, have similar variations in process and outcome measures.

SCOAP has been launched as a physician-led program, in partnership with other stakeholders, to promote data-driven quality improvement activities across Washington. The Washington State Chapter of the American College of Surgeons strongly supports SCOAP and urges its membership to facilitate SCOAP participation in the hospitals in which the members practice. In addition SCOAP has the support of Washington’s surgical leadership, major state agencies, and major health plans.

What is the relationship between SCOAP and the State of Washington?

State agencies across the nation are increasingly requiring the collection of outcomes data, and using the data to generate public report cards. Washington State has elected to pursue a different approach. The central premise of SCOAP is that quality of care can best be enhanced through collaborative, not punitive, mechanisms. No state agency will be authorized to review physician- or hospital-identified data without appropriate consent from the respective party. Instead, the SCOAP Management Committee will share with the State blinded data reports demonstrating general trends in surgical care, and will outline how it has responded to any concerns about quality of care. The HCA strongly encourages hospitals to participate and contributes to program planning and development in an advisory role.

Who ‘runs’ SCOAP?

SCOAP is housed at and staffed by the Foundation for Health Care Quality, a private, not-for-profit organization that also facilitates COAP and other QI programs and projects. The Foundation serves the health care community as a neutral, safe harbor for data-driven quality improvement activities. SCOAP policy and strategic decisions are formulated by its Management Committee, comprised of leading surgeons from across the state in partnership with hospital administrators and representatives from other stakeholder organizations, including the Health Care Authority.

What procedures are included in SCOAP, and why?

The initial set of procedures are appendectomies, colon procedures (colectomies, proctectomies), and bariatric procedures. These were included for initial focus because the feasibility work described earlier identified them as high-volume, high variation in process and/or outcome, and/or growing in volume. They are only a few procedures done by general surgeons that can be analyzed by hospital chart review and have significant opportunity for improvement in care and/or outcome. Additional procedures will be added over time as SCOAP matures.

How does SCOAP compare to other programs whose goal is to improve processes and outcomes, such as the National Surgical Quality Improvement Program (NSQIP), the Surgical Care Improvement Project (SCIP), and the Institute for Healthcare Improvement’s 100,000 Lives Campaign?

SCOAP is a quality improvement program, not an accreditation mechanism or a data registry. It has been developed and will be led by Washington State surgeon and hospital leadership, state agencies, and other stakeholders.

SCOAP’s key attributes are the following:

  • Protection of data from disclosure via its CQIP status – and the ability of SCOAP to decide its own evolution on matters of disclosure and public accountability.
  • Commitment to quality improvement, not punishment or exclusion.
  • The leadership of hospitals and surgeons in guiding program development and strategy.
  • SCOAP’s process and outcome variables include both generic and disease- and procedure-specific measures.
  • Many variables and definitions are common to SCOAP, NSQIP, and SCIP.
  • Quick turn-around on meaningful data: comparative reports returned to hospitals within two months of the quarter’s end; benchmarking facilitates quality improvement efforts.
  • The flexibility to select surgical procedures of interest in response to public health needs and interests.
  • The development of a community of providers who can learn from one another in a trusted, collaborative environment.
  • Eventual universal participation by eligible hospitals.
  • The ability to use the data for in-hospital QI projects.

How will SCOAP help improve surgical care and outcomes?

SCOAP participants receive regular reports of hospital-level data that provide the information they need to effectively make improvements in care by comparing and tracking their own processes and outcomes: surgeons and hospitals will identify opportunities to improve outcomes and identify unexpected outcomes and can benchmark themselves to their colleagues across the state.

How can I contribute to program development?

Hospitals that chose to participate early in SCOAP's implementation (late 2005 and in 2006) have had the greatest opportunity to shape program elements such as data definitions, processes, and report formats. There are also important ways to contribute by participating in subcommittees, workgroups, and meetings. You may also contact individually the Medical Director, Program Director, or any member of the Management Committee.

Who is paying for this program?

Funding for this program is multifaceted. Support of the “start-up” phase was provided by several sources: the Health Care Authority contracted with the Foundation for Health Care Quality to organize and facilitate a secure and confidential statewide quality improvement program; the Foundation, under whose auspices SCOAP operates, has provided staffing for essential infrastructure and development. Several other entities, including health plans, have contributed grants to support this work. Additional funding sources include grants and fees from participating hospitals.

What happens if a hospital chooses not to participate?

Participation in SCOAP is voluntary. An important goal of SCOAP is to avoid such coercive measures and create an atmosphere of collaboration and partnership in an effort to better serve patients in this state. The value that SCOAP provides—procedure- and disease-specific, clinically-pertinent, timely information for quality improvement—will help hospitals with their decisions to participate in SCOAP.

Summary

SCOAP offers unique benefits to Washington hospitals and surgeons and to the public. Participation in SCOAP does not preclude participation in other programs, and may be complementary to them. SCOAP data should be useful to hospital administrators for multiple purposes (e.g., patient safety, process improvement quality improvement projects, JCAHO accreditation evaluation). Perhaps most important, SCOAP is an opportunity for Washington State payers and health care administrators to work jointly with surgeons to improve the quality of care without turning over that responsibility to a national organization.