The Surgical Care and Outcomes Assessment Program (SCOAP)

Focus: 

To define, measure and improve the quality of surgical care practices

Anticipated Impact: 

Widespread adoption of best surgical practices to prevent unnecessary procedures and mistakes

Abstract: 

Emerging healthcare technology offers hope to cure disease and ease suffering, but there are few restrictions on clinicians' use of healthcare technology and no surveillance regarding its safety and effectiveness once in the field. This lack of surveillance allows gaps in quality and increases healthcare costs. Across Washington State the use of emerging, minimally invasive surgical procedures for obesity, colorectal cancer, aneurysms and vascular disease is highly variable and when they are used there appears to be nearly 5-fold variation between hospitals in the occurrence of serious complications. Tracking the variation in use of healthcare technologies between hospitals will directly facilitate outcomes improvements and more cost-effective healthcare.

The Surgical Care and Outcomes Assessment Program (SCOAP) is a prospective, surveillance system focusing on hospital-based technology. SCOAP delivers timely data on appropriate use, effectiveness and safety to clinicians and hospitals and facilitates technology integration teams to transform these data into strategies to reduce inappropriate surgical care. Through the Life Sciences Discovery Fund award, SCOAP will expand to include nearly 50 hospitals in its quality improvement network and add surveillance of new and emerging healthcare technology procedures to ensure in-field effectiveness. We anticipate that SCOAP-participating hospitals will have better short and long-term safety outcomes in the use of new/emerging technology than non-SCOAP-participating hospitals and that SCOAP hospitals will provide more cost-effective care to their patients. Additionally, we aim to improve public knowledge of surgical quality of care by promoting public reporting of SCOAP safety, use and outcome data.

See also:

Surgical Best Practices

Grant Update

Principal Investigator:
David Flum
Grantee Organization:
University of Washington
Grant Title:
Surgical Care and Outcomes Assessment Program (SCOAP)
Grant Cohort and Year:
2007 Beneficial Applications of Technology in Health Care: Improving Health-Care Quality and Cost Effectiveness (01)
Grant Period:
01/01/2008 - 12/31/2011 (Completed)
Grant Amount:
$1,285,222
SCOAP began in 2006 as a collaborative of 10 hospitals, and as of December 2011 includes 56 hospitals, representing almost all the hospitals in the state where surgical care is delivered. Original procedures included colorectal operations, appendectomy and bariatric surgery. We added vascular and pediatric surgery modules over the initial 3-year grant period, and modules in spine, urology, and high-risk procedures (esophagectomy, pancreatectomy and hepatectomy) have been in development over this yearlong project extension period. Progress in enrolling hospital into this voluntary initiative-the largest hospital collaborative for surgical QI-has been facilitated by word of mouth and peer-to-peer recruitment. SCOAP has focused on creating a value proposition for surgeons and hospitals to join. The SCOAP components that are reported by surgeons and hospital leadership as “value added” include providing actionable data in a timely fashion rather than a simple “report card” of mortality, allowing smaller hospitals and surgeons to demonstrate that they deliver highest quality surgical care even if they have smaller procedural volume, convincing state legislators to not require surgeon/hospital reporting of outcomes using administrative data, linking of surgeons into a peer network, meeting the requirements for Part 4 of the American Board of Surgery Maintenance of Certification program, and helping surgeons direct local QI activities to issues they care about and are of importance to their patients. In its first 6 years, SCOAP has transitioned to focus energy on creating an active response to data that show disturbing variability. Surgeons in all hospitals now participate in the use of standardized orders/templates and a SCOAP Surgical Checklist (www.SCOAPchecklist.org). The SCOAP Surgical Checklist Initiative introduced a 3x5 foot checklist into every operating room in the State of Washington. This checklist was modified from an earlier version of the World Health Organization’s checklist that was pilot tested at one of our SCOAP hospitals and modified to include metrics that are relevant to surgeons in the United States and that are consistently being missed among SCOAP hospitals (e.g., confirming plans for the continuation of beta blockers after procedure among those patients receiving them before surgery) while removing metrics that are more relevant in developing countries. “Checklisting” is one part of creating an active response to pathologic variability. In other examples of decreasing gaps in variability in surgical care practices, SCOAP has demonstrated improvements in the rates of negative appendectomy and has tracked improvements in important process of care measures such as pathologists’ capture of 12+ lymph nodes in the operated specimens of patients with colon cancer and the checking of blood glucose among diabetic patients having elective surgery. SCOAP also demonstrated reduction in the rates of the adverse outcome of anastomotic leak after colorectal surgery by encouraging the use of a simple intra-operative “leak test” (distending the submerged and reattached colon with air/saline/methylene blue solutions) before the abdomen is closed. ”Leak testing” in the operating room identifies potential problems while the patient is still under anesthesia and before a leak can cause harm post-operatively that can lead to reoperations and increased risk of death. Over the past 2 years, SCOAP hospitals increased the use of leak testing while the adjusted rate of re-operation dropped from 7.1% during the first 4 quarters of the average hospital’s SCOAP participation to 4.7% in their last 4 quarters. SCOAP has also developed into an effective platform for developing the next generation of QI metrics and for comparative effectiveness research (CER). CER focuses on the comparative effects of different treatment strategies in the “real world” rather than the typical research environment. SCOAP includes patients from diverse practice environments; currently SCOAP hospitals include 34 centers that serve rural areas and 23 that serve urban areas. SCOAP sites perform 90% of surgical care delivered in the State, including almost all members of “priority populations” for research funding agencies (e.g., pediatric and elderly populations, minority groups and those with comorbid conditions) as well as subjects who may not otherwise participate in clinical research (e.g., lower socioeconomic status, far distance to larger medical centers). SCOAP data are high quality (audited and verified) and based in the general community so they may be viewed as more generalizeable. The data are also collected prospectively with the full intent to perform CER with careful attention to risk-adjustment and selection of variables included. Furthermore, SCOAP data has been coupled to records from ambulatory surgical centers, statewide payer billing and pharmacy systems, the state’s vital status registry, and a post-discharge survey assessment center. It also links to Washington State’s Comprehensive Hospital Abstract Reporting System (CHARS), one of the nation’s only discharge data systems that maintain coded patient identifiers for each admission. These data linking creates a unique longitudinal data, incorporating almost all relevant data streams related to surgical care and outcome and creating a research record of events and outcomes. Taking advantage of this, SCOAP has been expanding research activities in its partnership with University of Washington’s (UW) Centers for Comparative and Health System Effectiveness (CHASE Alliance) serving as its academic home. SCOAP has developed a streamlined process for the use of data in CER activities operating within the centralized purview of Washington State’s Institutional Review Board. In October 2010 the University of Washington was awarded an $11.7 million grant from AHRQ to leverage SCOAP’s QI activities into a CER network that could be used for multiple clinical questions. In October 2011, LSDF recognized the work of the CER network infrastructure by awarding an additional $2.3 million grant for additional infrastructure building and CER study development. During this yearlong no-cost extension period, SCOAP has added modules of surveillance in spine, cancer, and urologic surgery, in order to widen SCOAP’s clinical sphere of influence in Washington State. In addition, the SCOAP Survey Center has been further developed and widely implemented among SCOAP modules to make SCOAP data collected more robust and complete in its snapshot of surgical care.

Impact in Washington

Location of LSDF Grantee
Locations of Collaborations/Areas of Impact
Seattle
Issaquah
Aberdeen
Anacortes
Bellevue
Burien
Colfax
Colville
Coupeville
Davenport
Edmonds
Ellensburg
Everett
Federal Way
Grand Coulee
Ilwaco
Kirkland
Longview
Morton
Moses Lake
Mount Vernon
Olympia
Omak
Othello
Port Angeles
Port Townsend
Puyallup
Redmond
Renton
Richland
Shelton
Spokane
Sunnyside
Tacoma
Vancouver
Wenatchee
White Salmon
Yakima
Joint Base Lewis-McChord
Sedro-Woolley
Lakewood
Enumclaw
Gig Harbor
Auburn
Bellingham
Forks
Prosser
Walla Walla

Legislative Districts:
3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 19, 20, 21, 22, 24, 25, 26, 27, 28, 29, 30, 31, 32, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 45, 46, 47, 48, 49

Health Impacts

Surgical Best Practices

Mar 21, 2010
The Seattle Times
Jun 25, 2008

WHO Safe Surgery Initiative Launch Coincides with SCOAP Research
Seattle Times  |   Seattle P-I  |   New York Times  |   National Public Radio