Improving Surgical Outcomes Through Surgeon-specific Reporting: A Quality Improvement Initiative

Introduction: Quality improvement programs are essential to enhance surgical patient safety and outcomes. However, reliance on administrative data for benchmarking can introduce errors and lack relevant details. We incorporated surgeon-specific data and a group-based strategy for inpatient operations to improve mortality, length of stay (LOS), and readmissions at a tertiary care center with an open surgeon staffing model. Methods: A dashboard, created using Vizient (Irving, TX) data, included LOS index, mortality index, and procedure-related readmissions with outcomes tracking at individual surgeon-level. Group outcomes data were updated monthly. Individual reports were provided quarterly to surgeons, and designated leaders developed quality improvement programs per surgery type. Practice-specific group data (thoracic, surgical oncology, acute care surgery, bariatric surgery, general surgery, two colorectal surgery units, and minimally invasive surgery) were presented monthly, and leaders shared program implementation details annually or semiannually. Differences over time were calculated via t-test. Improvement strategies were also tracked. Results: Over three years (2021-2023), 33 surgeons conducted 8145 inpatient operations. Quality improvement strategies included refined surgical patient candidate selection, proactive involvement of palliative care for high-risk patients, adoption of standard clinical pathways (enhanced recovery after surgery), more robotic surgery, and documentation improvement. Mortality rate decreased from 0.64 to 0.17 (P = 0.003); LOS index reduced from 0.97 to 0.92 (P = 0.03). Procedure-related readmissions were stable. Conclusions: Surgeon-specific group-based strategies may help increase adoption of surgical protocols and techniques to improve surgical outcomes. This program highlights the importance of collaborative and data-driven strategies for enhancing patient care quality.