On Developing the Tools and Metrics for a Neurosurgical Quality Program


With the current trends in the healthcare environment, it has become essential to develop means with which to improve quality, patient satisfaction, and efficiency while reducing costs. These mounting pressures are affecting how the neurosurgeon practices, how the neurosurgeon is evaluated, and how the neurosurgeon is compensated. Neurosurgical engagement in this continuous evolution of healthcare policy is imperative. Neurosurgeons should be the ones developing best practices and guidelines for neurosurgical care. Also, they must determine the processes to ensure that others are implementing those best practices. Development of a quality/safety program to measure and analyze neurosurgical complications and outcomes is a means with which to implement initiatives aimed at improving that performance. Determining which tools and metrics with which to measure quality and safety, patient satisfaction, and efficiency or throughput is essential.


Quality, Safety, Value, Cost, Metrics, Performance measures


  • Outline

  • Mission and Goals 39

  • Stakeholders 41

  • Initiatives, Metrics, and Benchmarks 43

  • Organization of Data 45

  • Communication 46

  • UTSW Division of Pediatric Neurosurgery 46

  • Conclusion 50

  • References 51

Over the past two plus decades, the entire landscape of healthcare has shifted and continues to evolve. More patients are receiving both care and increasingly complex treatments. The quality of care and the cost of that care have become significant issues. As a result, many are of the belief that the quality is poor and the system is wasteful.

Indeed, a “wake-up call” was delivered in 1999 from the Institute of Medicine (IOM) with its publication: To Err is Human. Building a safer health system, it was reported that up to 98,000 people a year die because of medical mistakes in hospitals. That document made a clear and unambiguous observation citing patient safety as a major problem affecting quality and cost of medical care. It concluded that “better care” must be “safe,” “efficient,” “effective,” “equitable,” “evidence based,” “patient-centered,” and “timely.” The IOM directed efforts at fixing or correcting the healthcare system.

Efforts to fix and reform the healthcare system have been immense, often mandated by the federal government. There has been a steady increase in development, testing, and implementation of new safe practices, protocols, and procedures by hospitals and providers throughout the country. Physicians and hospitals, insurers, rating agencies, and the government have started to focus strongly on quality and safety. There has thus been a proliferation of metrics and ratings to assess and measure these efforts. Hospital-led quality and safety programs have been created to monitor these data.

Policy changes in healthcare are now focused on the measurement of multiple factors that include health status, quality of care, patient safety, indications of care, and long-term outcomes. The passage of the Patient Protection and Affordable Care Act (ACA) in 2010 is the latest attempt to provide universal access to healthcare, a focus on population health, payment reform, and cost control. The mounting pressures on providers and the numerous changes in healthcare are affecting the way the neurosurgeon practices, how the neurosurgeon is evaluated, and how the neurosurgeon is compensated.

Neurosurgical engagement in the continuous evolution of healthcare policy is imperative. No longer will the neurosurgeon be able to simply show up to evaluate a patient, to operate on a patient, and to care for the patient. They must be aware of these changing policy dynamics and ensure that appropriate adjustments are made to deliver the best possible care while staying current and preparing for the future. The development of a dedicated initiative or program to measure, monitor, and affect change in quality and safety provides such care. Participation in a comprehensive quality and safety program allows the neurosurgeon to promote effective change and improvement in care, to maintain a role in leadership and structure, and to have a say in reimbursement models.

Further, a quality and safety program in neurosurgery provides the opportunity to measure and positively influence care specific to the neurosurgical patient. No other individual knows what the neurosurgical patient needs other than the neurosurgeon. The design and implementation should include multiple strategies to define the exact goals, establish and engage the key stakeholders, define and determine the metrics, establish the resources necessary for data collection and their accuracy, and promote future growth and evolution.

Development of a comprehensive neurosurgical quality and safety program is an investment. However, it is one that is well worth it from a patient care perspective, as well as from a reimbursement perspective and a perspective to influence the future direction of neurosurgery. There are many facets that go into such development.

There are multiple steps involved in the development of a neurosurgical program in quality and safety to measure performance. Basic or key elements must be established to implement the initiative. The goal or purpose behind the program must be defined or determined. The reasons why an organization should develop and promote a Q/S program need to be addressed. The stakeholders must be established and is necessary. Who is going to participate in the development and implementation of the program? The metrics to be measured and assessed must be defined. Resources to analyze and monitor those metrics are needed. Effective modes and a schedule of communication are imperative. Also, the program needs to be adaptable to changes in practice and the healthcare environment.

Mission and Goals

The organization that hopes to develop and implement a successful quality and safety program should first define its mission. It must first determine the reason for having the program. Is the institution concerned about external rankings? There are obvious questions about the accuracy and meaningfulness of such data. Are there financial implications? Does the organization want to improve value? Reforms generated by Q/S programs lead to a reduction in costs and improvement in efficiency. Will the institution use its data to evaluate providers or procedures? It can certainly affect how providers work, how providers are evaluated, and how providers are compensated. The most frequently used and important reason for a Q/S program is the desire to improve the overall care to its patients.

An organization may decide to use the data generated by the quality/safety program for innovation and strategic growth, financial success, and reputation. Many embrace the concept of linking payment with quality. Policymakers hope to link payment with service. That service must meet certain standards. Without the metrics to evaluate the quality of care, it is going to be difficult to maintain a viable practice. In addition, patients or their family members cannot often judge or completely comprehend quality and outcomes. However, they can understand cost and satisfaction, which can be impacted by a successful Q/S initiative. Additionally, information gleaned from the program may allow an organization to identify needs and areas of care that can be expanded. Expansion may not be simply volume or demand based.

Data derived from the quality program can lead to changes in management and care that can directly affect or reduce cost. With the changing financial landscape and various payment models, information derived from the program’s initiatives could provide support for improved reimbursement and payment. Participation in a program that provides information on outcomes provides an organization advantages as we transition from a volume system of reimbursement to systems that are based on evidence, quality, and cost containment. Gains in leverage with insurers and employers are significant and can usually offset the cost of data acquisition of the quality and safety program. Offering a lower cost product with excellent outcomes to an insurer or large employer can provide a distinct advantage over a competitor. The organization can likely provide compelling reasons that their “product” is preferred with the information generated by the quality and safety program.

Cost efficiency is extremely important for financial success. Focus on a variety of processes can improve long-term efficacy, reduce costs, and promote responsible utilization of resources. Evaluation of processes in the OR, on the floor or in the ICU, and on utilization of imaging and pharmaceuticals leads to improved outcomes, reduction in complications and costs, and improved satisfaction. With enough numbers to average risk, data can even begin to reflect performance of specific procedures and specific neurosurgeons.

Determining a neurosurgeon’s value, and hence compensation, is difficult in the current healthcare environment. Payment based solely on demand and productivity is challenging and no longer effective. Pure productivity models may lead to an increase in unnecessary procedures, provide less control of complications with resultant increased costs, and limit care to highly complex or complicated issues that would deter from production. Incorporating data analyzed from participation in the quality and safety initiatives may provide a better valuation of a provider. Compensation linked in part to value and quality results will yield improved care, reduction in costs, and greater efficiency.

It seems that the primary goal of a quality and safety program should be in the improvement of overall care. The program is not necessarily aimed at managing physicians, nurses, or procedures, but to provide a framework for the process of care. Data derived can be used to direct and implement the best processes that improve the overall delivery of care. It can improve efficiency of care in the operating room, in the hospital or intensive care units, and in the ambulatory setting. Guidelines and protocols of care can be developed. Pathways to reduce morbidity and mortality of specific conditions, minimization of pain and disability, and improvement in the quality of neurosurgical care can be developed. Improvement in multiple areas such as quality and safety, patient satisfaction, and throughput and efficiency can be expected.


An integral part of an effective quality and safety program is its composition. If the focus of the program is truly to improve care and maintain reliability, cooperation on the part of all of the providers and caregivers and of the organization’s administration is essential. Safety and quality depend on having unified teams of like-minded people willing to put all normal human and professional differences aside to achieve a common goal. The common goal is that everything done is done for the best interests of the patient. It is not the responsibility of one group, but the involvement of everyone, from the CEO to the housekeeping staff, that is integral for success. A strong partnership between the medical staff, the nursing staff, and administration is needed. Commitment of all is necessary to develop a culture of safety and quality. Development of an engaged and high performing program is based on a team that embraces the principle of wanting to provide the best possible care. A common theme of these successful programs is teamwork. Success requires an open, supportive, mutually reinforcing, and dedicated relationship among all participants, irrespective of their respective job or function. An understanding that there is value to what each professional brings to a patient encounter is necessary. Collegiality and mutual respect of one another, irrespective of what degree one holds or how much experience one may have, is a necessity and often is counter to history, personalities, and past culture. The initial work to develop a quality and safety program involves a buy-in from everyone.

The neurosurgeon must be engaged in the process and in the leadership of the effort. Their patients and results are included. They understand the pathology and the care delivery process. Neurosurgeons should be the ones developing best practices and guidelines for neurosurgical care. Also, they must determine the processes to ensure that others are implementing those best practices. They are the ones best equipped to determine how to improve the care process over time. The neurosurgeon knows the appropriate clinical information and how to interpret it. Administrators do not. Hospital and health systems can use administrative data to some degree to assess quality through the CMS Hospital Compare program or the Surgical Care Improvement Project (SCIP). These data, however, lack clinical information and are limited by the variables that are reported for claims only. More importantly, the correlation between administrative data and actual complications or diagnoses is inadequate. The neurosurgeon can comprehend and utilize clinical data to highlight what areas of care need to be improved and how to do so. Finally, neurosurgical participation in the leadership of the program is important to ensure adequate representation and fair distribution of resources.

Neurosurgeon engagement is not simple. Changes in practice developed and implemented by the quality and safety efforts may vary from past practice patterns. Program leadership will need to work with staff neurosurgeons and providers to relinquish the past while creating and sustaining a new future. Inclusion of the clinician or neurosurgeon to assist in the determination of programmatic priorities, design of what metrics to track, how to measure and analyze those metrics, and implementation of changes based on those results is helpful. Identify a specific clinician to be a champion for a respective area of priority. That individual will be accountable and will help ensure progress. They will identify the specific aims for improvement, the interventions that will be implemented, and a timeline for completion of those aims. Change can be empowering when the clinician is involved in the process.

There may be other means with which to attract a provider’s enthusiastic participation. Incentives and a financial bonus structure can be tied to Q/S outcomes as a means of improving or increasing specific neurosurgeon cooperation. Instead of simple productivity benchmarks for salary, the bonus structure can be aligned with results on individual and group results on various performance measures such as infection rates, LOS, and patient satisfaction. Additional financial incentives to enhance the program can be earned under what some refer to as “good citizenship.” Collection of data is dependent upon consistent and timely physician participation. Using metrics that include professionalism, timely documentation and submission of charges, regular attendance at quality meetings, and meeting meaningful use requirements can be utilized to support the bonus structure.

Education and support are beneficial. The use of educational programs that promote quality and safety competencies and that offer information on such can be useful. Courses are available to demonstrate the importance of safe, highly reliable teams and to instruct development of the essentials of quality and safety agendas. They offered through many different avenues and are available off site, on site, in many instances, and on line. Some programs have even utilized required reading materials. Emphasis on these educational programs is a means with which to build support.

A strong organizational and management commitment is necessary at every administrative level. Success of a program requires cooperation and shared decision making with the respective organization’s administration. Significant resources for implementation and support are not without significant cost. It is hoped that the results of the efforts will offset those costs.

Again, the involvement of all caregivers is necessary for success. Multiple individuals can comprise the quality team and can contribute to the design and implementation of programmatic initiatives. Physicians in critical care, emergency room care, hospital medicine, neuroradiology, and anesthesia all have priorities and functions that affect the care of the neurosurgical patient. Collaboration with these medical specialists can further impact the program agenda and also be included within a program. Similarly, nursing staff, physical and occupational therapists, pharmacists, case managers, social workers, and ambulatory administrative staff can be included in a successful team.

A position dedicated to ensuring the progress of the departmental quality program is essential. A director of quality is necessary to champion the efforts, assess progress, and help set new goals. The individual directs an administrative quality staff. The individual must also be the liaison between those staff and the clinicians or providers who direct the initiatives. The director also provides effective and timely communication with the organization’s leadership.

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Apr 21, 2019 | Posted by in NEUROSURGERY | Comments Off on On Developing the Tools and Metrics for a Neurosurgical Quality Program
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