When it comes to having surgery, many people associate large urban hospitals with having the best surgical programs. But in rural Ontario, on the shores of Georgian Bay, the surgical program at Grey Bruce Health Services is on par with some of the world’s leading hospitals.
Last November, a meritorious award from the American College of Surgeons’ (ACS) National Surgical Quality Improvement Program (NSQIP) was awarded to GBHS for the 2018 calendar year — proof that the hospital corporation is not only on the right track, but among the best. Other hospitals who achieved this recognition include the Mayo Clinic, Johns Hopkins, the Cleveland Clinic, and Toronto’s Sunnybrook Health Sciences Centre.
“There is a cost associated with the program, so administrative financial support is needed,” said Dr. Al Lozon, surgeon champion of the program at GBHS. “Although these programs easily pay for themselves in cost savings, a significant proportion of initial adopters abandon it due to the yearly cost.”
Costs arrive in the form of data extraction, increased workload for OR and other staff, new bladder scanners, etc. But “cost savings are huge, patients do better, length of stay is less, return trips to the ER are reduced,” added Dr. Lozon.
The outcomes evaluated for the program are: mortality; cardiac arrest and heart attack; pneumonia; unplanned intubation; ventilator use for more than 48 hours; renal failure; surgical site infections and urinary tract infections.
Data is extracted using the ACS data methodology and targets a mix of surgical procedures. Outcomes are assessed at 30 days after surgery.
As part of the program, changes were made in protocols from advising the patient on how to prepare themselves for surgery, to how the patient is prepped for surgery, changes to antibiotic stewardship, changes to general surgical orders, warming the patient before and during surgery, careful glucose monitoring, tweaks in cleaning and sterilizing regimens and more.
The team effort is the key to the program’s success, said Michele Turcotte, Director, Surgical and Women Child Program at GBHS. Surgeons, nursing staff, clerical staff, the clinical reviewer responsible for data extraction, OR suite attendants and others all had to hop on board. “It involves a lot of people to get such great outcomes. It’s a true team achievement.”
The fact that urinary tract infections and surgical site infections have markedly decreased has made a difference in patients’ lives, stressed Dr. Lozon. “Even before the program, patients could feel confident in having their surgery at GBHS and this remains unchanged after the program. We were good before the program and now we’re in the top 10 percent.”
Dr. Lozon highlights good data extraction as key to the program.
“I’ve learned the importance of quality data, and the difference between quality improvement with measured outcome improvement,” versus phantom quality improvement measurements for the sake of change that “either makes things worse or is of no benefit,” he said.
“Ultimately, the program allowed us to identify where our problems were (UTI and SSI) and direct us to implement quality improvement plans directed at these issues. It also showed us where we were doing well (pneumonia, DVT) and allowed us to not direct excess time and resources towards these issues.”
Staff buy-in is often an early obstacle. It was “baby steps,” said Turcotte. “That’s why you need to have that surgeon champion (Dr. Lozon) to take the lead, and isn’t afraid to sometimes have those difficult conversations with individuals.” Change takes work and effort, she said, “and when people start seeing good results, then you get the buy-in into the program. It’s step by step, you have to be patient with it.”
GBHS was one of just nine Canadian hospitals —and the smallest — to receive the ACS distinction for 2018.
For Dr. Lozon, what’s stunning about the accomplishment is not so much the size of the hospital, but that GBHS, which operates five small hospitals and one regional centre, was “able to do it as a geographically dispersed corporation that offers surgical services at multiple sites. That’s a more significant accomplishment than being small. The staff and team coming together to facilitate this is again, obviously, a source of pride.”
It’s great news for patients that GBHS has been able to sustain its quality surgical improvements, said Turcotte. “For a patient choosing to have surgery here at Grey Bruce Health Services, they’re pretty much guaranteed that they’re going to have a good outcome post-op.”
GBHS has been participating in NSQIP since 2014 and reports outcomes based on the eight clinical areas every six months.