Ontario’s operating rooms are busy: surgeons performed over 600,000 scheduled operations [1] in the province in 2016-2017, with C-sections, knee and hip replacements, bone surgery and heart-related surgery among the most common inpatient procedures.[2] All surgical teams routinely track efforts to protect patient safety, including those that prevent complications. For example, recent data[3] show high uptake on steps to avoid surgical site infections: Ontario’s hospitals report 98% compliance in giving hip and knee replacement patients antibiotics before surgery to avert infection (range: 80-100%).

How can more data support better outcomes for patients? Tracking detailed surgical data before, during and after each operation can show hospitals and surgical teams exactly where they can improve patient outcomes.

An international program developed by the American College of Surgeons in 1994 — known as the National Surgical Quality Improvement Program — takes this approach. It collects and compares detailed clinical information from all stages of patient surgery. It looks at 14 specific outcomes — ranging from whether a patient developed an infection or breathing problems to severe outcomes, like death. The program is designed to improve the quality of care before, during and after an operation. It includes outcomes even after a patient leaves the hospital, which is when some complications may develop.

The program’s data do not identify patients to protect their privacy, but are adjusted by age and pre-existing illnesses to make sure that comparisons are relevant. That means that comparisons account for differences in how sick patients are, such that hospitals that treat sicker patients are not unfairly compared to those with healthier patients.

Though the program began in the U.S., it has expanded internationally and now includes 31 Ontario hospitals as members: The Ottawa Hospital was the first to sign on in 2010, followed by Sunnybrook Health Sciences Centre, the University Health Network and Hamilton Health Sciences.

In 2015, the province officially launched a surgical quality improvement initiative. These hospitals voluntarily participate in the Ontario Surgical Quality Improvement Network, which connects hospitals as they collectively work to improve care. The current 31 members span hospitals that treat both adults and children and represent organizations of all sizes — from urban to community and rural hospitals — as well as all regions of the province.

Other provinces in Canada participating in the broader program include British Columbia, Alberta, Saskatchewan, Quebec and Newfoundland. All participating provinces share their data in an international database.

The data sharing allows each of the nearly 700 member hospitals around the world to see how they are doing relative to their peers and where they have room to improve.

Linda was hoping for a smooth recovery. After having emergency surgery to fix a bowel obstruction in 2016, she arranged for a home care nurse to help out. She’d had multiple hernia and bowel operations over the past 14 years and wanted to avoid complications, like infection, this time.

The nurse monitored the surgical incision and changed the dressing, but complications developed and the wound reopened. Linda also developed Clostridium difficile, a common infection.

With her medical history, Linda had a higher risk of common complications, notes Dr. Michael Lisi, chief of staff at Collingwood General and Marine Hospital. Because of this, she represented exactly the kind of patient a surgical quality improvement program aimed to help. Repeat visits and complications are hard on patients like Linda, he adds. “She’s been in and out of hospitals,” he says. “These are the individuals [who] require our attention for prevention.”

When Linda first became Lisi’s patient a few years ago, the hospital had not yet joined the program. At that time, the hospital didn’t have as clear a picture of post-surgical complications, says Lisi, “we just knew that complications happened.”

By the time she needed emergency surgery in 2016, the hospital had adopted some of the program’s best practices to improve recovery and minimize surgical site infections. Since Linda’s surgery was an emergency procedure, she couldn’t be part of the full Enhanced Recovery After Surgery process, which includes specific pre-op education and diet steps for patients to follow. However, she benefited from the hospital’s surgical site infection practices. “She’s a good example of [ the patient experience ] before the program,” he says. “Now that it’s underway, we’re now able to identify areas to focus improvement initiatives.”

After joining the program in 2015, Collingwood General and Marine has reduced its surgical site infection rates from 3.4% to 2.4% between January and July 2017. Lisi notes that the hospital continues to expand its quality improvement strategies. “We’re also working on length of stay and readmission, and have been identifying our pneumonia rates — those are slightly high — and we’re exploring why this is the case.”

Linda didn’t know that the hospital was part of a quality improvement program until later. “I thought it was great,” she says. After a nine-day hospital stay to treat the Clostridium difficile infection, she returned to the wound clinic each week, where specialists took pictures of her incision to track her progress. As she healed, she returned monthly and then less frequently.

Now, she’s fully recovered, and recalls charting her progress by the length of walks she took. First, she and her husband would walk down the street until they reached a small bench a short distance away. Gradually, they went further, eventually making it up and down their town’s main street, and along the waterfront.

How is she feeling now? “Really good. I’m back at work full time. I’m feeling great.” She looks back on her surgical journey with relief that the complications — and the hospital trips — are behind her. “I spent too much time there.”

Dr. Duncan Rozario knows that even minor adjustments in surgical practices can yield big benefits, especially when it comes to better patient recovery. “It may be only a 0.1% change here, a 0.1% change there,” but the total effect of all those small changes adds up to lower surgical complications, he says.

When Oakville Trafalgar Memorial Hospital joined the quality improvement program in 2015, Rozario’s role was to determine where those changes were most needed.

After measuring patient outcomes for six months, the hospital found that its surgical site and urinary tract infection rates ranked poorly. The hospital —  part of Halton Healthcare — was one of the first Ontario hospitals in the program to implement a set of changes meant to prevent infection before, during and after surgery.

Halton Healthcare implemented seven program steps at the Oakville hospital: some involve the patient, having them shower with a hospital-grade antiseptic the night before and the morning of surgery. That practice has had good adoption, notes Rozario. “Most people are happy to do things to improve their surgery outcomes,” he says.

The hospital also refers patients to public health smoking cessation programs well before their surgery date. Smokers have a higher risk of pneumonia, blood clots and wound infections, Rozario says, noting that even the use of a nicotine patch for a month before surgery is far better for patient outcomes. Although those efforts have been slower to catch on, the overall results have been positive: “After six months, our surgical site infection rate dropped by half, [when] we were expecting maybe a 25% improvement,” he says.

Outside the operating room, Rozario points to an overall shift in mindset about general surgical patients — especially those with perforated colons, who historically experience high wound infection rates. “Those high numbers aren’t acceptable anymore,” he says.

He appreciates that the program lets hospitals here compare their progress against so many innovative hospitals in the U.S. “It pushes everyone to do better, here in Ontario,” he notes. “Sometimes you need a protocol and a program and a group behind you to make real change.”

Dr. Ravinder Singh believes in borrowing what’s working at other hospitals. So, when North Bay Regional Health Centre joined the quality improvement program, he already had a goal in mind: “I’m always thinking what can we do to make patients feel better, get home faster and stay home,” the hospital’s head of surgery says.

To do that, he looked to the on-call emergency surgeon concept, which has surgeons forego elective procedures like surgery, endoscopy and clinic for a week, dedicating that time to patient rounds in acute care. That concept, first developed at U.S. hospitals, had documented fewer complications and shorter hospital stays there. 

Since adding the on-call concept, the overall stay for general surgery patients admitted through emergency has gone down by two days, he says.  For appendicitis patients, it’s down by more than half a day, and for emergency gall bladder patients, “it’s a full day shorter,” he says. The sickest patients have benefited the most from the on-call surgeons in emergency, he notes, because the extra attention prevents further complications.

The hospital has also rolled out the Enhanced Recovery After Surgery program, which is meant to empower patients with their own care. When Singh learned of Mount Sinai Hospital’s post-surgery patient activity booklet — part of the recovery program, he adopted it for North Bay.  Patients are encouraged to fill out the booklet in detail, answering questions like, ‘Are you doing deep breathing?’ , ‘What did you eat and drink on day 1? Day 2?’ and ‘when did the catheter come out?’

Singh thinks the program is revolutionary in its challenge to surgical status quo. “It was developed to question the dogma around how we treat surgical patients,” he says.

Adding to those efforts, Singh has inspired others to pursue continuous quality improvement and has promoted surgical site infection prevention steps to other hospitals in the program. “It’s all about connecting and learning from each other,” he says. “Big or small, academic or non-academic hospital, we’re all trying to reach the same goals.”

In the early days of William Osler Health System’s quality improvement efforts, Dr. Rardi van Heest found that people returned to the emergency department within 30 days of surgery for different reasons.

Pain was a major factor. Patients may not know how to use pain medication properly, a risk to them and their household if they had unused medication lying about, she notes.  Post-surgery patients also visit emergency for non-urgent conditions, including constipation, vomiting, swelling and redness around a surgical incision.

Van Heest and her team thought that if patients knew what to expect when they went home, the visits might decrease. So, they developed a Surgeon Discharge Instruction Sheet, outlining normal symptoms like gas pain, constipation and incisional pain. It also highlighted symptoms that required follow-up with the surgeon’s office, such as fever greater than 38.5 degrees or pain that wasn’t controlled by medication.

Within three months of using the instruction sheets, emergency visits by this group dropped by half. Van Heest is now sharing the sheet with other surgeons in the Ontario surgical quality improvement network so that more hospitals can benefit.

Next, she wanted to get a better sense of the patient experience. The hospital had already successfully reduced its surgical incision infection and urinary tract infection rates using the quality improvement program’s Enhanced Recovery After Surgery steps, and van Heest wanted to build on that. “I want to get a barometer of how we’re doing, right away,” she says. “I don’t see a lot of [research] on how the patients think their surgeries went.”

Many patients at Brampton Civic and Etobicoke General Hospitals are first-generation Canadians, she says, noting that English may not be their first language. This presented a challenge to the hospital’s surgical clinical reviewers, who speak to patients after surgery. She added two questions — related to patients’ overall surgical experience and how they felt it could be better — to the program’s standard questions. After gathering feedback from 400 patients at both hospitals, the results showed general satisfaction with interactions with hospital staff, particularly nurses; and less satisfaction in understanding system processes, wait times or post-surgical pain.

To improve their experience, patients have suggested more access to physiotherapy and follow-up care and greater staff availability for patients in need. “If a patient isn’t happy, regardless of what the documented outcome is, then we haven’t done our job,” she says.

The Methods Notes provide a brief description of the data and methods used in this report. For more details, please see the American College of Surgeons National Surgical Quality Improvement Program website: https://www.facs.org/quality-programs/acs-nsqip

Data sources

The data presented in this report were provided by the American College of Surgeons National Surgical Quality Improvement Program, a program that builds a community of practice for surgical teams interested in surgical quality improvement. The program is based in the United States, and has an international membership that currently includes nearly 700 hospitals. A community of 31 hospitals at present across Ontario form the Ontario Surgical Quality Improvement Network.[7,8] Data are presented in this report for the 29 adult hospitals.

Hospitals that participate in the program collect clinical data on randomly selected surgical patients from the pre-operative period through to 30-days post-surgery.[7] Hospitals submit data to the program, which conducts risk-adjusted analysis on a defined set of postsurgical complications for all hospitals and the local network, and reports the data back to the hospitals by means of Semi-Annual Reports. Hospitals can view their data and see comparisons of their performance with other hospitals in their collaborative and to the larger network.[7]

The data used in this report were extracted from the July 2017 National Surgical Quality Improvement Program Ontario Collaborative Semi-annual report.[9]

List of Surgeries

The following is a list of surgical groups included in this report:

• Orthopaedic Surgery (excluding podiatry)
• Oncology Procedures
• General and Abdominal Surgery
• Gynaecologic Surgery
• Neurosurgery
• Plastic and Reconstructive Surgery
• Head and Neck Surgery
• Urologic Surgery
• Vascular Surgery

Analysis

Methodology[8,9]

The program provided hospital performance data for a number of patient complications within 30 days post-surgery: Clostridium difficile colitis, ventilation for over 48 hours, unplanned intubation, pneumonia, return to operating room, venous thromboembolism, readmission, heart complications, renal failure, sepsis, urinary tract infection, and surgical site infection, as well as data for two summary measures, morbidity and mortality. For more detailed definitions on the complications, please see the American College of Surgeons National Surgical Quality Improvement Program website: https://www.facs.org/qualityprograms/acs-nsqip.

The program fits the data for each postsurgical complication to hierarchical logistic regression models that are weighted and risk-adjusted across all hospitals in the full collaborative to produce an odds ratio for each hospital.

Ontario’s performance

This report uses the program methodology that identifies the percentage of hospitals within the Ontario collaborative that fall into each of three program performance categories (‘better than expected,’ ‘as expected,’ ‘needs improvement’) for each post-surgical complication for Figure 4. For each hospital within each indicator, a performance categorization was assigned based on whether the hospital odds ratio a) fell into an extreme decile or b) was an outlier.

• Extreme decile ranking. All odds ratios of the program hospitals in the international collaborative (including the Ontario collaborative hospitals) are ordered from smallest to largest and assigned to 10 equally sized sequential groups (deciles) representing 10% of all program hospitals. In this manner, we can see how the Ontario hospitals compare to hospitals in the program’s international collaborative. A hospital with an odds ratio in the first decile is within the 10% of hospitals that are the highest performers and a hospital with an odds ratio in the 10th decile is within the 10% of hospitals that are the lowest performers.
• Outlier. A hospital is determined to be an outlier based on the confidence intervals for the odds ratio. If the confidence interval for a hospital is entirely above the value of 1.0, then the hospital is considered to be a high outlier (a hospital has a higher likelihood of a post-surgical complication). Conversely, if the confidence interval for a hospital is entirely below the value of 1.0, then the hospital is a low outlier (a hospital has a lower likelihood of a post-surgical complication). If the confidence interval contains 1.0, then the hospital is not an outlier (a hospital is doing as expected).

‘Better than expected’ performance is attributed to hospitals that are doing very well in comparison to other program hospitals for a post-surgical complication. This status is assigned to hospitals that had a decile rank of 1 or were low outliers. ‘Room for improvement’ status is assigned to hospitals that are not doing as well as other program hospitals for a postsurgical complication. This status is assigned to hospitals that had a decile rank of 10 or were high outliers.

‘As expected’ status is attributed to hospitals that are doing similarly in comparison to other program hospitals with regard to a postsurgical complication. This status is assigned to hospitals that had a decile rank of 2-9 and were not outliers.

Building off of the NSQIP methodology, we have highlighted the specific post-surgical complications where Ontario hospitals show higher performance or where there is room for improvement. Higher performance post-surgical complications are those that the program identified as having all hospitals performing ‘better than expected’ or ‘as expected’ for those complications. Post-surgical complications with ‘room for improvement’ are those that the program identified as having the largest percentage of hospitals that were in the ‘room for improvement’ category. For other post-surgical complications, the majority of hospitals performed ‘better than expected’ or ‘as expected.’

This report uses the program methodology that reports solely on decile ranking of hospital odds ratios across all hospitals for Figures 2 and 3. Please see the section above for decile ranking methodology. Figures 2 and 3 only display the ranks of Ontario collaborative hospitals, however all program hospitals were used to produce the decile ranking. For more information on the methodology please see the American College of Surgeons National Surgical Quality Improvement Program website: https://www.facs.org/quality-programs/acs-nsqip.

Health Quality Ontario thanks the patients and providers, Linda, Dr. Duncan Rozario, Dr. Michael Lisi, Dr. Ravinder Singh and Dr. Rardi van Heest for sharing their experiences and insights for the stories and quotes in this report.

This report was developed by a multi-disciplinary team from Health Quality Ontario, including Heather Angus-Lee, Pierrette Price Arsenault, Tricia Beath, Maria Bennell, Lisa Bitonti-Bengert, Susan Brien, Shirley Chen, Jethro Cheng, Naushaba Degani, Gail Dobell, Ryan Emond, Terri Goveia, Louise Grenier, Binil Tahlan, Mina Viscardi-Johnson and Dave Zago.

Health Quality Ontario also acknowledges and thanks the American College of Surgeons National Surgical Quality Improvement Program® who provided clarification on methodology and data for the report, namely Emma Malloy, Gina Pope and Vanessa Thompson.

Parts of this material are based on data and information compiled and provided by CIHI. However, the analyses, conclusions, opinions and statements expressed herein are those of the author, and not necessarily those of CIHI.