Assessing Episode-Based Surgical Quality in VA and Community Care Settings

背景：自近30年前国家外科质量改进计划启动以来，弗吉尼亚州 一直走在手术质量测量和改进的前沿。这项工作的大部分都是 重点评估风险调整后的术后并发症，较少关注重要护理 流程，甚至更少关注评估和提高整个手术过程的质量 护理，包括术前阶段。调整现有和新的措施以可靠和 随着退伍军人使用退伍军人人数的增加，准确评估整个外科护理的连续性将会增加。 购买的社区护理(CC)。虽然三分之一的VA患者接受CC，但质量评估还远远不够 与退伍军人管理局内接受护理的患者相比，CC患者的发展程度较低。 意义：质量评估的重点是术后结果和并发症， 整个手术过程中的护理质量在很大程度上被忽视了，特别是及时性、过度使用、 在手术前阶段使用不足。明确的护理插曲，构成提供给 治疗临床疾病，已被提升为评估提供者之间的质量、协调和成本 参与病人的护理。尽管退伍军人管理局还没有使用情节模型来监控质量，但退伍军人管理局已经 有机会使用手术插曲框架来更广泛地衡量手术质量，了解 此方法的价值，并告知未来VA交付和VA购买的CC的质量报告需求。这个 鉴于VA的快速增长，检查手术过程质量的重要性更加突出。 购买了CC，不可避免地需要确保在所有设置中保持质量。 创新和影响：本提案的目标是开发一种创新模型来衡量条件- 具体的手术过程质量，包括术前、围手术期和术后护理阶段，共3个 复杂程度各不相同的程序。这项工作将通过以下方式促进质量测量科学的发展 在整个手术过程中进行评估。在将该模型应用于现有的VA和CC数据时，我们将 在退伍军人医疗中心发现提高手术质量的新机会，并将促进- 具体比较VA和CC设置之间的剧集质量差异。我们还将确定限制 在使用现有的CC数据源进行CC相对于VA的剧集质量评估时。 具体目标：目标1：为手术过程质量评估确定特定条件的质量指标。目标 2：衡量退伍军人医疗中心基于事件的质量测量的绩效差距和可靠性。 目的3：评估基于情景的质量测量在CC环境中应用的可行性。 方法：目标1：我们将根据已确定的事件测量确定新的质量衡量标准 差距。德尔福专家小组将对新提出的质量措施进行表面有效性、重要性和可行性的评级 包括在手术病历质量测量模型中。目标2：我们将应用剧集质量 VA国家数据的测量模型(在目标1中定义)，以评估场馆级别的剧集质量变化 并测量模型的可靠性，以描述退伍军人设施的性能。目标3：使用质量衡量标准 适用于VA和CC管理数据源，我们将比较VA和CC的剧集质量 在类似的医疗保健市场中的设置，确定应用事件质量测量的限制 对现有CC数据进行建模，以进行有意义的VA和CC质量比较。 下一步/实施：我们将利用这项研究的结果与合作伙伴合作，完善和 将测量模型扩展到其他手术条件，以更广泛地提高退伍军人的护理质量， 在退伍军人事务部和CC环境下确定合作改进质量的目标，并提供建议 用于改进CC的剧集质量测量。这项工作也可以被合作伙伴用来告知 他将协助退伍军人管理局领导做出“做还是买”的决策。

Background: Since initiation of the National Surgical Quality Improvement Program nearly 30 years ago, VA has been at the forefront of surgical quality measurement and improvement. Much of this work has been focused on assessing risk-adjusted postoperative complications, with less attention paid to important care processes, and even less attention to evaluating and improving quality across the full continuum of surgical care, including the presurgical period. The importance of adapting current and new measures to reliably and accurately assess the full continuum of surgical care will increase as greater numbers of Veterans use VA- purchased Community Care (CC). While one out of three VA patients receive CC, quality assessment is far less developed for CC than for those receiving care within the VA. Significance: With the focus of quality assessment being on postoperative outcomes and complications, quality of care across the entire surgical continuum is largely ignored, especially issues of timeliness, overuse, and underuse in the presurgical period. Defined episodes of care, which constitute a set of services provided to treat a clinical condition, have been promoted to assess quality, coordination, and cost among providers involved in a patient’s care. Although episode models have not been used by VA to monitor quality, VA has the opportunity to use a surgical episode framework to measure surgical quality more broadly, understand the value of this approach, and inform future quality reporting needs for VA-delivered and VA-purchased CC. The importance of examining surgical episode quality is even more salient given the rapid increase in VA- purchased CC, with an inevitable need to ensure that quality is maintained across all settings. Innovation and Impact: The goal of this proposal is to develop an innovative model to measure condition- specific surgical episode quality, including pre-, peri-, and postoperative care phases, for 3 common procedures of varying complexity. This work will advance the science of quality measurement through assessment across the entire surgical continuum. In applying this model to existing VA and CC data, we will identify new opportunities for surgical quality improvement in VA medical centers and will facilitate a condition- specific comparison of episode quality differences between VA and CC settings. We will also identify limitations in episode quality assessment for CC relative to VA using existing CC data sources. Specific Aims: Aim 1: Define condition-specific quality measures for surgical episode quality evaluation. Aim 2: Measure the performance gap and reliability of episode-based quality measures across VA medical centers. Aim 3: Assess the feasibility of applying episode-based quality measurement in the CC setting. Methodology: Aim 1: We will identify new quality measures in response to identified episode measurement gaps. A Delphi panel will rate the newly proposed quality measures for face validity, importance, and feasibility for inclusion in the surgical episode quality measurement model. Aim 2: We will apply the episode quality measurement model (defined in Aim 1) to VA national data to assess facility-level variation in episode quality and measure the reliability of the model to profile VA facility performance. Aim 3: Using quality measures applicable to both VA and CC administrative data sources, we will compare episode quality in VA and CC settings within similar healthcare markets, identifying limitations in applying the episode quality measurement model to existing CC data for meaningful VA and CC quality comparisons. Next Steps/Implementation: We will use the findings of this research to work with partners to refine and expand the measurement model to other surgical conditions to improve care quality for Veterans more broadly, identify targets for cooperative quality improvement within VA and CC settings, and provide recommendations for improvement of episode quality measurement for CC. This work can also be used by partners to inform Veteran choices and will assist VA leaders to inform “make versus buy” policy decisions.