Assessing operative autonomy Combining theory and software to make evaluation easy

Jonathan Fryer MD,Professor of Surgery, Feinberg School of Medicine, Northwestern University

Disclosures

• I have made no financial gains from this project• I may in the future• I intend to continue work on this project regardless

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What is the most essential goal of surgical training?

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Operative Autonomy

• The ability to independently perform operations safely and effectively.

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The Problem

There is growing concern that graduating surgical residents are not achieving operative autonomy with essential procedures.

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1. Bell RH. Why Johnny cannot operate. Surgery 146, 533–542 (2009).2. Mattar SG et al. General Surgery Residency Inadequately Prepares Trainees for

Fellowship: Results of a Survey of Fellowship Program Directors. Annals of Surgery September 2013 258, 440–449 (2013).

3. Coleman JJ et al. Early Subspecialization and Perceived Competence in Surgical Training: Are Residents Ready? Journal of the American College of Surgeons 216, 764–771 (2013).

4. Chen P. Are Today’s New Surgeons Unprepared? Well (2013). at http://well.blogs.nytimes.com/2013/12/12/are-todays-new-surgeons-unprepared

The Problem

• To be able to fix it…… You have to be able to measure it.

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The Problem

• We don’t do a very good job of assessing residents in the OR.

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The Problem

– Currently, summative assessment of OR performance is based on:• # of cases logged by resident

– Role of resident in each case?

• Semi-annual global evaluations – Memory decay?

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The Problem

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…asking busy surgical faculty to fill out complex assessment forms in a timely manner, doesn’t work.

The Solution

A simple assessment tool that:• Assesses operative autonomy• Doesn’t impede surgical workflow• Facilitates high compliance and

prompt completion

Theoretical Framework

• Inter-related constructs: – Supervision, Guidance, Autonomy, Performance

• Faculty Supervision (oversight) ≠ • Faculty guidance (physical or verbal help)

• 1 • Faculty Guidance = Resident Autonomy

• Resident Autonomy = ƒ (Resident performance)•

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The Solution

– With every case faculty:• Provide resident supervision.• Assess and document the

level of operative autonomy achieved by the resident.

• Progressively reduce the level of operative guidance they provide to resident.

The “Zwisch” Scale

• 4 levels of operative guidance– Show & Tell– Active Help– Passive Help– Supervision Only

DaRosa, D. A. et al. A Theory-Based Model for Teaching and Assessing Residents in the Operating Room. Journal of Surgical Education 70, 24–30 (2013).

Our method: PASS (Procedural Autonomy and Supervision System)

Today

Coming soon…

Study Design: Participants and Setting

• Department of general surgery at a large academic hospital

• All teaching faculty underwent formal frame-of-reference training per published protocol1

• All general surgery residents and trained faculty raters eligible for inclusion

• IRB-approved

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1George et al, J. Surg. Educ. 2013; 70

Results: Feasibility

• A 1 hour rater training session is sufficient to achieve reliable and accurate ratings1

• 92% response rate using PASS

1George, B. C. et al. Duration of Faculty Training Needed to Ensure Reliable OR Performance Ratings. J. Surg. Educ. 70, 703–708 (2013).

Results: PASS Sample (7 mos)

Number of Residents 31 By Year of Residency Year 1 Year 2 Year 3 Year 4 Year 5 9 6 5 5 6Number of Attendings 27Number of Procedures 1490 Number of Types of Procedures

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Results: PASS Sample

Relative Case ComplexityEasiest 1/3 Middle 1/3 Hardest 1/3193 (13.0%) 895 (60.1%) 402 (27.0%)

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Results: Validity: Zwisch Levels by PGY

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p-values for sequential pair-wise

distributions

p=<.001

p=<.001

p=<.001

p=0.21

23.2%

Results: Validity: Zwisch Levels by Complexity

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p-values for sequential pair-wise

distributionsp=<.001 p=<.001

Results: Validity: Zwisch Level by Prior Experience

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p-values for sequential pair-wise

distributionsp=<.001

Study Design: Data Collection

• Sample 2: Video Sample– 8 procedures video recorded for additional review

(subset of PASS sample)– Rated by operating faculty, in-person OR observer, and

video reviewer using Zwisch scale (blinded to other scores)

– Rated by 2 additional video reviewers using other OR assessment instruments (modified OPRS and O-SCORE)

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Results: Video Sample

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Number of Residents 4 (PGY 2 to 5)

Number of Attendings 2Number of Procedures 8Number of Types of Procedures 5

2 Laparoscopic cholecystectomy2 Open inguinal hernia repair2 Parathyroidectomy1 Total thyroidectomy1 Laparoscopic ventral hernia repair

Results: Reliability

• Inter-rater reliability– Zwisch ratings – Operating attending, OR observer, and video rater – ICC = .90, 95% CI = .72 - .98, p < .001.

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Item ρ p-value

Operative Performance Rating System (OPRS)     Degree of prompting or direction -.92 .001 Instrument handling .94 .005 Respect for tissue .94 .005 Time and motion .94 <.001 Operation flow .95 <.001 Overall performance .95 <.001Ottawa Surgical Competency OR Eval. (O-SCORE)     Knowledge of procedural steps .94 <.001 Technical performance .93 .001 Visuospatial skills .92 .001 Efficiency and flow .86 .007 Communication .92 .001

Results: Validity: Zwisch Level correlation with other OR assessment tools

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Benefits

• Faculty and residents constantly reminded of ultimate goal …. i.e. operative autonomy.

• Establishes a conceptual framework for teaching and learning in the OR.

• Data can be used to: – Help faculty and residents to set learning goals.– Help programs monitor operative progress and identify those

who may need additional attention.– Address regulatory requirements for OR supervision and

operative performance assessment.– Establish national norms

Limitations

• So far, studied only at a single institution• Validity analysis based on small convenience sample• Raters not blinded to resident PGY level • Comparison with only selected items of OPRS and O-

SCORE• Unmeasured confounders (time of day, supervising surgeon

experience, etc)

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Conclusion

• The Zwisch rating scale is a reliable and valid measure of faculty guidance and resident autonomy

• Deployed on PASS the Zwisch scale can be used to feasibly record evaluations for the vast majority of operations performed by residents

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Vision

• All surgical subspecialties.• Other procedural specialties.• Other medical professionals who need to learn to perform

complex clinical tasks.• Other trades or professions where trainees need to learn

to independently perform complex tasks safely and effectively.

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AcknowledgementsSurgical Education Research & Development Team

Jay Zwischenberg

er

Eric HungnessShari Meyerso

nDebra DaRosaJonatha

n FryerEzra

Teitelbaum

Brian George

Mary Schuller

Research supported by:

Excellence in Academic Medicine Program from the State of Illinois

Augusta Webster Educational Innovation Grant from the Northwestern University

Center for Education in Medicine

Theoretical basis

• Global assessment of performance is simpler, more accurate, and more reliable than checklists1

• Faculty guidance is related to resident performance2

• Faculty can accurately and reliably rate the amount of guidance provided to residents3

1. Regehr, G., MacRae, H., Reznick, R. K. & Szalay, D. Comparing the psychometric properties of checklists and global rating scales for assessing performance on an OSCE-format examination. Acad Med 73, 993–997 (1998).

2. Chen, X. (Phoenix), Williams, R. G., Sanfey, H. A. & Dunnington, G. L. How do supervising surgeons evaluate guidance provided in the operating room? The American Journal of Surgery 203, 44–48 (2012).

3. George, B., Teitelbaum, E., DaRosa, D., Hungness, E., Meyerson, S., Fryer, J., Schuller, M., Zwischenberger, J. Duration of Faculty Training Needed to Ensure Reliable O.R. Performance Ratings. Journal of Surgical Education 70(6), 703-708 (2013).

Study

• Over 7 months• 1490 evaluations • 27 faculty • 31 residents

Study Design: Rating Scales

• Zwisch• Procedural Complexity• Operative Performance Rating System (OPRS)1

– 6 general items only--excludes items that pertain only to specific procedures

• Ottawa Surgical Competency Operating Room Evaluation (O-SCORE)2

– 5 intra-operative items only--excludes items that did not pertain to intra-operative performance.

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1Chen et al, The American Journal of Surgery 2012; 2032Gofton et al, Acad. Med. 2012; 87

Results: Validity

• Convergent Validity for Guidance/Autonomy and Resident Performance– Zwisch level vs. PGY– Zwisch level vs. Complexity– Zwisch level vs. Resident Experience

• Construct Validity for Guidance/Autonomy– Zwisch level vs. OPRS guidance item

• Construct Validity for Resident Performance– Zwisch level vs. OPRS performance items– Zwisch level vs. O-SCORE performance items

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The Team

• Dr. Debra DaRosa• Dr. Brian George• Dr. Shari Meyerson• Dr. Ezra Teitelbaum• Mary Schuller• Dr. Nathaniel Soper• Dr. Joseph Zwischenberger

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Impact so far

• Over 1000 evaluations collected in 6 months• Response rate > 90%• Changes in teaching• They love to use it!

Next steps

• Dictation of feedback• Reports

Results: Validity

• Convergent Validity for Guidance/Autonomy and Resident Performance– Zwisch level vs. PGY– Zwisch level vs. Complexity– Zwisch level vs. Resident Experience

• Construct Validity for Guidance/Autonomy– Zwisch level vs. OPRS guidance item

• Construct Validity for Resident Performance– Zwisch level vs. OPRS performance items– Zwisch level vs. O-SCORE performance items

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Theoretical Framework

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Helping Watching

Next Steps

• I am actively trying to bring this to MGH• It needs additional development before it can be launched

here• Multiple other departments have already committed to

supporting this project

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Questions?

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1 2 3 4 5

Supervision Levels for PGY5 Residents0

4080

Num

ber o

f pro

cedu

res

Residents

Results

Results

50% = 60 procedures

Current Status

Milestone Achieved Cost / timeDevelopment of v1.0 mobile app

$200,000 / 8 months

Development of v0.9 administrative interface (beta)

$75,000 / 3 months

Integration with Northwestern EMR

$45,000 / 2 months

Development of v2.0 iOS app

$160,000 / 7 months (ongoing)

Total $480,000 + operational expenses

Road Map

Planned Technical Milestones

Target launch date

v2.0 for iOS at Northwestern February 2014v1.0 Administrative interface at Northwestern

April 2014

v2.0 for Android at Northwestern

June 2014

System integration at MGH June 2014v2.0 iOS at MGH July 2014V2.0 Android at MGH October 2014

12 month budget

Expense Item CostDesign and specification $30,000Software Development $225,000-$300,000QA testing $30,000Server hosting and maintenance

$25,000

User training $5,000Administrative $30,000Total $345,000 -

$420,000

The “Zwisch” Scale

• 4 levels of guidance– Show & Tell– Active Help– Passive Help– Supervision Only

DaRosa, D. A. et al. A Theory-Based Model for Teaching and Assessing Residents in the Operating Room. Journal of Surgical Education 70, 24–30 (2013).

 

Faculty  Guidance     ∝ 1Resident   AutonomyResident  Autonomy     ∝ 1Faculty  Guidance

Theoretical Framework

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• Stritter FT et al., Handbook for the academic physician. 1986.

• Chen et al., The American Journal of Surgery 2012; 203• Gofton et al., Acad. Med. 2012; 87