no financial conflicts of interest 2013 naffziger …...solution that are used daily for the...

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2013 Naffziger Lecture

Carlos A. Pellegrini MD FACS

The Henry N. Harkins Professor and Chair

Department of Surgery

University of Washington

Disclosures

No financial conflicts of interest

Officer of the American College of Surgeons

Founding member of one of organizations I will discuss today

The Surgeon as a Leader: Improving Quality, Decreasing Costs

Leadership

Quality Costs

Defining leadership

Leadership is a combination of a meaningful vision with the ability to influence others by non-coercive means.

Leadership is personal and is exercised using values and styles that must fit the circumstances (time, environment, etc.)

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IS THIS A NEW CONCEPT?

Surgeon’s role in leadership as it relates to Quality of Care

“End Results” – The Vision

Ernest Amory Codman, MD

5/17/2013 6

"We believe it is the duty of every hospital to establish a follow-up system, so that as far as possible the result of every case will be available at all times for investigation by members of the staff, the trustees, or administration, or by other authorized investigators or statisticians."

Codman’s Books – Reprinted

5/17/2013 7

Quack Medicine - Then

The Hype: Reality:

CNS Disorders

Compromised Organ function

Vitamin Deficiency

Headaches

Diarrhea & Abdominal Pain

5/17/2013 8

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Dubious Hair Growth Products

The Hype:“Discover the All-Natural Formula that’s Clinically Proven to Help You Retain and Regrow Your Hair.

If you are a man concerned about stopping hair loss, Our Product (Procerin) can help. It comes in a convenient tablet form and topical solution that are used daily for the treatment of male hair loss. It is an all-natural supplement available without a prescription. And, it has no side effects.”

5/17/2013 9

“There is a special place for people who complain about the healthcare system but do nothing to change it….it’s called

the doctors’ lounge”

1. QUALITY DEFINEDTaking on the “challenge”

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Quality in Medicine

The provision of care that is safe, effective, efficient, timely and patient centered for all those who are in need.

Crossing the Quality Chasm:A New Health System for the 21st Century

Quality in Medicine - Care

SAFE –primum non-nocere

EFFECTIVE – Evidence-based

EFFICIENT – No waste

TIMELY –

PATIENT CENTERED – preferences and values

UNIVERSAL – Reduce disparity

Crossing the Quality Chasm:A New Health System for the 21st Century

COSTS

The relationship of Quality to Costs -

The Next Era of Quality

Redefining Health Care: Creating Value-Based Competition on Results

Michael Porter, PhD

Elizabeth Olmsted Teisberg, PhD

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The Value Equation in Healthcare

Value = Health Care Outcomes

Dollars Spent

5/17/2013 17

The Goal of Value: To Guide Everyone’s Choices

5/17/2013 18

VALUE

The Value Compass

Bulletin of theACS May 2013

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Value Based Care

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National Tour Collecting health care leadership insights, best-practices and case studies from each tour stop to develop….

Exercising Leadership in QI

Identify practical opportunities for individual surgeons in the areas of� Training

� Certification

� Participation in National Programs of Quality

� Creation of Regional Programs

� Creation of Local Programs

� Teamwork The idea is how can You participate and Become a leader…..

Regardless of whether youWork in an Academic orIn a Private environment

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TRAININGFacing the challenge

Do not just “teach” – use training

Focus on the importance of Quality

Make Students-Residents-Fellows participate actively in safety and quality

Drive into them the notion of constant change

Create the ability to define “gaps”

Train to proficiency/competency/expertise

Training and Education of Residents

Knowledge Ability/dexterity

Values andAptitudes PROFESSIONAL

DEVELOPMENT /MOC

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Challenge yourself…..

Introduction of new technology� Is it for you?

� Is it in your field?

�Does meet “quality” criteria?

� Is it a gimmick?

Maintenance of Certification�Use the process to your advantage

4. THE ACS NSQIP(NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM)

A professional organization meets the Challenge

Program Overview

• ACS NSQIP is a data-driven, risk-adjusted, outcomes-based surgical quality improvement program.

Quality Improvement Process

1. Hospitals abstract data.2. Data are analyzed by ACS NSQIP.3. Data are reported back to hospitals.4. Targets for improvement are identified5.Hospitals act on their data.6. Hospitals monitor interventions with data.

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0

1

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99% Confidence interval

Low Outlier

High Outlier

Overall (Multispecialty) 30-Day Morbidity O/E Ratio s1/1/2007 - 12/31/2007O/E

Ratio

Report Identification Number

Interpretation of Results

Observed to Expected (O/E) Ratio• Hospital’s outcomes compared to the other ACS-NSQIP hospitals, adjusted for inter-hospital differences in patients’ characteristics, comorbidities, and preoperative laboratory values

LOW OUTLIER: If the upper bound of the O/E confidence interval is <1.0, the hospital’s outcomes are statistically better than expected. Thus, the hospital’s outcomes are “Exemplary.”

ACS NSQIP Hospital ID Number

HIGH OUTLIER: If the lower bound of the O/E ratio is >1.0, the hospital’s outcomes are statistically worse than expected. Thus, the hospital’s outcomes “Need Improvement.”

AS EXPECTED

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99% Confidence interval

Low Outlier

High Outlier

Overall (Multispecialty) 30-Day Morbidity O/E Ratio s1/1/2007 - 12/31/2007O/E

Ratio

Report Identification Number

Interpretation of Results

ACS NSQIP Hospital ID Number

Over-Time Performance• Represents the hospital’s previous O/E ratios from the 10 most recent semi-annual reports

Current O/E Ratio

Low Outlier

High OutlierAs Expected

General Surgery 30-DayMortality

Observed Rate: 0.91%Expected Rate: 1.04%O/E Ratio: 0.88Status: As Expected

General Surgery30-Day Morbidity


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General Surgery: Cardiac Complications


General Surgery: Pneumonia


General Surgery: Unplanned Intubation

Observed Rate: 2.15%Expected Rate: 1.28%O/E Ratio: 1.68Status: Needs Improvement

General Surgery:Ventilator >48 Hours

Observed Rate: 2.49%Expected Rate: 1.62%O/E Ratio: 1.54Status: Needs Improvement

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General Surgery: DVT/PE


118 Hospitals in NSQIP 2005-2007

Reduced Complications

Reduced Disparities of Care

Improved Overall Quality

Ann Surg 2009

SURGICAL CARE AND OUTCOMES PROGRAM (SCOAP)

Creation of Regional Programs

Washington State initiatives to improve

surgical outcomes

Focus in process and outcomes

Led by Surgeons

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What is SCOAP?

A surgeon-led collaborative using a data driven quality surveillance and response system to deliver more appropriate, safer and higher qualitysurgical care across the Pacific Northwest

How does it work?� Surveillance of surgical process and outcome metrics

� Compares to other hospitals and to benchmarks

� Focused on a given operation

� Created and monitored by surgeons

What does SCOAP provide?

• Washington State program targeting quality and cost-effectiveness

• Clinicians define metrics and hospitals track them • Improve through benchmarking and intervention

� SCOAP Reports � SCOAP Regional meetings� SCOAP Box newsletters� SCOAP Interventions� SCOAP ROI

Surgeons Get “Signal”

SCOAP has 3 high-level signalsRed=Metrics that are greater than one standard deviation away from SCOAP average

Yellow=Metrics that do not reach the SCOAP average

Green= Metrics that meet or exceed the benchmark performance rate

Note: Metrics in gray are at least meeting the SCOAP average, but do not meet the benchmark rates

How To Read A SCOAP Report

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Who runs SCOAP?

Administrative home� Foundation for Healthcare Quality

Research/creative home� University of Washington Department of Surgery’s

Surgical Outcomes Research Center (SORCE)Clinician-based advisory boardFunding� Hospital pays abstractors and modest yearly fee � Life Science Discovery Fund supported expansion

The Scope of SCOAP

SeattleSpokane

Yakima

•Wenatchee

Richland

Port Townsend

Sunnyside

Aberdeen Kirkland

Portland

Longview

Port Angeles

Mt Vernon

Tacoma

Olympia

Variability in Processes of Careand Outcomes in WA state

SCOAP Data

Variability in Outcome

Bile duct injury in Washington State 1987-2004

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

3.50%

0 5 10 15 20 25 30 35 40Hospital

% C

BD

Inju

ry

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Variability in Process

Use of Cholangiography in Washington State

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

0 10 20 30 40 50 60 70 80 90

Hospital

% IO

CColorectal Surgery Outcomes

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

90-day mortality

Time Trends

SCOAP Data 2006 - 2008

Colon Resection Reoperation RateBy Hospital, 1987-2004

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

0 10 20 30 40 50 60 70 80 90 100

Before SCOAP Variability

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Colon Resection ReoperationSCOAP data 2009

0%

5%

10%

15%

20%

25%

30%

35%

40%

SCOAP Hospitals

Pre-SCOAP

~1500 fewer reoperations

Re-operative ComplicationsElective Colon Resection

Testing for Leak in OR Prevents Reoperation After OR Driving Evidence-Based Surgery

Avoiding Transfusion in Elective General SurgeryAvoiding Transfusion in Elective General Surgery

0%

20%

40%

60%

80%

100%

2006 Q1 07 Q2 07 Q3 07 Q4 07 Q1 08 Q2 08 Q3 08 Q4 08 Q1 09

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Driving Evidence-Based Surgery

0%

20%

40%

60%

80%

100%

2006 Q1 07 Q2 07 Q3 07 Q4 07 Q1 08 Q2 08 Q3 08 Q4 08 Q1 09

Better Diabetes Management in ORBetter Diabetes Management in OR

Multi-Disciplinary

Proper Lymph Node Management in CancerProper Lymph Node Management in Cancer

0%

20%

40%

60%

80%

100%

Q1 06 Q2 Q3 Q4 Q1 07 Q2 Q3 Q4 Q1 08 Q2 Q3 Q4

2005-2010 Colorectal Surgery in WA

Non-SCOAP SCOAP

Cost 18,210 12,400

30-day mortality 2.4 1.4

Composite Adverse Events

31% 26%

30 day cost 20,550 16,850

Cost per day 3100 2700

18707 patients (8127 SCOAP)

Cost of Colo-rectal Procedure in relation to time in SCOAP

Among 18,707 procedures State of WA

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$10,000

$12,000

$14,000

$16,000

$18,000

$20,000

$22,000

2006 2007 2008 2009Non-SCOAP SCOAP

Bending the Cost Curve

$ 67.3 Million

Ave

rage

Cos

t/Cas

e (2

009

dolla

rs)

All SCOAP Procedures combined (35,994 patients)

Leadership and SCOAP

Leadership and SCOAP

First Public Campaign

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London, UK EURO EMRO

WPRO I

SEARO

AFRO

PAHO I

Amman, JordanToronto, Canada

New Delhi, India

Manila, Philippines

Ifakara, Tanzania

WPRO II

Auckland, NZ

PAHO II

Seattle, USA

The Checklist was piloted in 8 cities

Outcomes before and after Checklist

Haynes A et al. N Engl J Med 2009;360:491-9

Checklist and Safety

DeVries et al, studied the effects of a comprehensive checklist � 6 hospitals (2 academic, 4 large community)

� Comprehensive (preop, intraop, immediate post-op, late post-op to discharge)

� Multidisiplinary list – surgeon, nurse, anesthetist, assistant (all responsible for parts of checklist)

� 3 months before list, vs 3 months a year after introduction of checklist

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De Vries et al,

Complications decreased

From 27.3% to 16.7%

Mortality decreased From

1.5% to 0.8%

Hospital Performance: Processbefore and after checklist implementation

50%

60%

70%

80%

90%

100%

BB cont'd PBG checked Normothermia DVT proph Abx on time

% of

electi

ve co

lon/re

ctal c

ases

Q1 2008


50%

60%

70%

80%

90%

100%


% of

electi

ve co

lon/re

ctal c

ases

Q1 2008 Q4 2009


50%

60%

70%

80%

90%

100%


% of

electi

ve co

lon/re

ctal c

ases

Q1 2008 Q4 2009

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Hospital Performance: Outcomesbefore and after checklist implementation

0%

2%

4%

6%

8%

10%

12%

Wound opened Reoperation CAE

% of

electi

ve co

lon/re

ctal c

ases

Q1 2008 Q4 2009

Focus on Decision Making: Hospital

PATIENT

DOCTOR’S OFFICE

OPERATING ROOM

Focus on Decision Making: Clinic

PATIENT

DOCTOR’S OFFICE

OPERATING ROOM

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What is Strong for Surgery?

State-wide public health campaign � Evidence-based practices to optimize the health of

patients prior to surgery

� 5 Pilot sites: � Virginia Mason

� Swedish

� Skagit Valley Medical Center� Harborview

� UW Medical Center

Optimizing nutrition

Smoking Cessation

Medications

Blood sugar control

Checklists

Why a Public Health Campaign?

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Average of 17 years before new knowledge from randomized clinical trials is incorporated into widespread clinical practice!

Public Health Campaign

Statewide awareness� Media events� Website

Mobilizing the community� Strategic partnerships

Surveillance and Feedback� Change in behavior

Learning Healthcare System in Washington State

QI Performance Surveillance

Translation of Research into Practice

Patient Voices Project

Stakeholder Engagement

Research and

Development

Comparative Effectiveness

Research Translational

Network

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www.strongforsurgery.org

The Surgeon as a Leader in QI

There are many opportunities….

All that it requires is willingness and commitment on the part of surgeons….

Everyone here can be an active participant…

The ACS offers a platform….

Go do it !

Change System/Individual Behavior

EducationSurveillance and Feedback

Administrative Changes

Peer to peer forces

PenaltiesRewards

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Ideal Change Team Members

Administration and hospital leadershipSurgeons

Practice Manager

RNs

MAsDietitians

Other office staff

ConclusionProgress and innovation in science and medicine have outpaced quality improvements in the delivery of careSociety is paying attention to the safety, efficacy and compassion with which medicine is appliedThere is an opportunity for surgeons to make a substantial impact in this areaSuch an impact requires moving beyond traditional measures Awareness and willingness to join the quality process is a first good step Commitment, not just involvement needed

7. AS A PERSON – AS AN INDIVIDUAL

What can the surgeon do?A. MONITOR FATIGUE

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sleep

40-hr awake

06-12

Lapses of attentions in health adults as a function of time awake (Dinges, 2000)

Logical reasoning performance:Effects of 1 and 2 nights without sleep on

From Heslegrave et al.

Failures to respond for 30 sec on a vigilance task across 42 hours of total sleep deprivation

From Konowal et al. (1999)

time of peak occurrence

7:00 to 8:00 a.m.

Failures to respond for 30 sec on a vigilance task across 42 hours of total sleep deprivation

Psychomotor performance as a function of hours awake relative to blood alcohol concentration

From Dawson & Reid (1997)

0.08

22 hours awake = 0.08 BAC

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Fatigue countermeasure experiments have also been undertaken in simulator and field experiments, such as those performed by the NASA Ames Fatigue Countermeasures Program. Experimental

sleep loss1Long-haul

flight crews3Obstructive sleep apnea2

minutes performing PVT

no sleep loss

1 night without sleep

before CPAP treatment

night flights without a nap

night flights with a nap

after CPAP treatment

1. Dinges et al. (1994)2. Kribbs et al. (1993)3. Rosekind et al. (1994)

Effect of experimentally, medically and occupationally-induced sleep loss on vigilance

“It’s impossible” said Pride

“It’s risky” said experience

“It’s pointless” said Reason

“Give it a try….” whispered the heart

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Improving Outcomes through Pre-hospital Checklists

• Clinician-led QI using clinical data

Focus on quality and cost-effectivenessData

Impacts behavior through:� Benchmarking� Education� Standard orders� Checklists

Focus on Decision Making

PATIENT

DOCTOR’S OFFICE

OPERATING ROOM

Why Nutrition?

Malnutrition is prevalent in surgical patients.Best determinant of surgical outcome.

Modifiable with appropriate intervention.

Immunonutrition may improve recovery.

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Why Blood Sugar?

Link between high blood sugar levels and SSIs• Hyperglycemia - doubled risk of SSI• In some studies 47% of hyperglycemic episodes were in

nondiabetics !

470 million people worldwide will have prediabetes by 2030 1

� 5%-10% per year will progress to diabetes

35% of US adults older than 20 yrs of age and 50%greater than 65 years had prediabetes in 2005-2008 2

Latham. Inf Contr Hosp Epidemiol. 2001;22:607Dellinger. Inf Contr Hosp Epidemiol. 2001;22:604Lancet 2012; 2279-22902011 US Department of Health and Human Services

Why Blood Sugar?

> 65 years� 1 in 4 will have diabetes� 2 in 4 are prediabetic

Over 90% of prediabetics and 25% of diabetics are unaware of their condition!

2011 US Department of Health and Human Services

Why Medications?

Some medications and Herbal remedies ↑ risk of bleeding� Aspirin can be safely continued

Beta-blocker continuation associated with fewer cardiac events and mortality

Chest 2012; 141:e326S-e350S JAMA 2008; 300(24):2867-2878 Ann Surg 2012; 255(5):811-819

Arch of Surg 2012; 147(5):467-473

Why Smoking?

Smoking is prevalent� 1/3 of all patients

Smokers have ↑ risk of complications� Pulmonary� Circulatory� Infectious� Impaired wound healing

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EducationSurveillance and Feedback

Administrative Changes

Peer to peer forces

PenaltiesRewards

Raising Awareness – Changing Practice

Working as a “team”

DOMAINS OF BEHAVIORAL MARKS

Briefing

Information Sharing

Inquiry

Vigilance and Awareness

Contingency Management

Mazzocco K, et al, Am J Surg 2009;197

Get Involved

• Attend Campaign Events

• E-mail: [email protected]

[email protected]

• Inform Your Colleagues and Constituents

• Visit the website: http://www.strongforsurgery.org

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THANK YOU! Healthcare 2013: The Challenges

Access

Quality

Safety

Cost CloseRelationship

1

10

100

1,000

10,000

100,000

1,000,000

Six Sigma:*Motorola: Medida estadistica de variacion en la que el “limite de tolerancia por producto defectuoso” se coloca a 3.4 defectos por million de unidades u oportunidades

U.S Airline flight fatalities/U.S. Industry Best of Class

Airline baggage handling

Breast cancerScreening (WA)

Detection &treatment ofdepression

Adverse drugevents

Hospital acquired infections

Hospitalized patientsinjured through negligence

1(69%)

2(31%)

3(7%)

4(.6%)

5(.002%)

6(.00003%)

Overall Health Care Quality in U.S.

(Rand Study 2003)

IRS Phone-in Tax Advice

U.S. birth defects

Recommendedwell-child visits (WA)

Treatment ofBronchitis (WA)

NBA Free-throws

Sources: modified from C. Buck, GE; Dr. Sam Nussbaum, Wellpoint; Premera 2004 Quality Score Card; March of Dimes

level (% Defects)

Def

ects

per

mill

ion

∑

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6. CREATE AND LEAD TEAMS

What can the surgeon do at a local level?

Communication Quality and Surgical Morbidity

Davenport. JACS 2007;205: 778-784

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Behavioral Marker Risk Index (BMRI)

• Briefing

• Information sharing

• Inquiry

• Vigilance and awareness

Adjusted Odds RatioRisk Factor Complication or Death

BMRI 4.82

ASA 1.51

Mazzocco. Amer J Surg 2009; 197: 678-85

Behavioral Marker Risk Index and Postoperative Complications

Mazzocco. Amer J Surg 2009; 197: 678-85

Errors happen:It is importantto “prevent” and to “rescue”

Clinical Trials, CER Studies

Guidelines

Performance Indicators

Surveillance

Outcomes

Education and

Feedback

Generation of Evidence

no financial conflicts of interest 2013 naffziger …...solution that are used daily for the...

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