2013 Naffziger Lecture Officer of the American College of Surgeons - - PowerPoint PPT Presentation
Disclosures No financial conflicts of interest 2013 Naffziger Lecture Officer of the American College of Surgeons Founding member of one of organizations I will discuss today Carlos A. Pellegrini MD FACS The Henry N. Harkins Professor and
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Carlos A. Pellegrini MD FACS The Henry N. Harkins Professor and Chair Department of Surgery University of Washington
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“End Results” – The Vision
Ernest Amory Codman, MD
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"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."
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The Hype: Reality:
CNS Disorders Compromised Organ function Vitamin Deficiency Headaches Diarrhea & Abdominal Pain
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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.”
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“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”
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Crossing the Quality Chasm: A New Health System for the 21st Century
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
Redefining Health Care:
Creating Value-Based Competition on Results
Michael Porter, PhD Elizabeth Olmsted Teisberg, PhD
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The Goal of Value: To Guide Everyone’s Choices
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VALUE
The Value Compass
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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
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Is it for you? Is it in your field? Does meet “quality” criteria? Is it a gimmick?
Use the process to your advantage
IMPROVEMENT PROGRAM)
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5.Hospitals act on their data.
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9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 1 2
99% Confidence interval Low Outlier High Outlier
Overall (Multispecialty) 30-Day Morbidity O/E Ratios
1/1/2007 - 12/31/2007 O/E Ratio Report Identification Number
Observed to Expected (O/E) Ratio
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
Improvement.” AS EXPECTED
9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 1 2
99% Confidence interval Low Outlier High Outlier
Overall (Multispecialty) 30-Day Morbidity O/E Ratios
1/1/2007 - 12/31/2007 O/E Ratio Report Identification Number
ACS NSQIP Hospital ID Number
Over-Time Performance
recent semi-annual reports
Current O/E Ratio Low Outlier High Outlier As Expected
Observed Rate: 0.91% Expected Rate: 1.04% O/E Ratio: 0.88 Status: As Expected
Observed Rate: 12.01% Expected Rate: 11.32% O/E Ratio: 1.06 Status: As Expected
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General Surgery: Cardiac Complications
Observed Rate: 0.17% Expected Rate: 0.4% O/E Ratio: 0.41 Status: As Expected
Observed Rate: 0.91% Expected Rate: 1.44% O/E Ratio: 0.63 Status: As Expected
Observed Rate: 2.15% Expected Rate: 1.28% O/E Ratio: 1.68 Status: Needs Improvement
Observed Rate: 2.49% Expected Rate: 1.62% O/E Ratio: 1.54 Status: Needs Improvement
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Observed Rate: 1.24% Expected Rate: 0.99% O/E Ratio: 1.26 Status: As Expected
Ann Surg 2009
Focus in process and outcomes Led by Surgeons
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A surgeon-led collaborative using a data driven quality surveillance and response system to deliver more appropriate, safer and higher quality surgical 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
cost-effectiveness
SCOAP Reports SCOAP Regional meetings SCOAP Box newsletters SCOAP Interventions SCOAP ROI
SCOAP has 3 high-level signals
Red=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
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Administrative home
Foundation for Healthcare Quality
Research/creative home
University of Washington Department of Surgery’s
Surgical Outcomes Research Center (SORCE)
Clinician-based advisory board Funding
Hospital pays abstractors and modest yearly fee Life Science Discovery Fund supported expansion
Seattle Spokane Yakima
Richland Port Townsend Sunnyside Aberdeen Kirkland Portland Longview Port Angeles Mt Vernon Tacoma Olympia
SCOAP Data
Bile duct injury in Washington State 1987-2004
0.00% 0.50% 1.00% 1.50% 2.00% 2.50% 3.00% 3.50% 5 10 15 20 25 30 35 40 Hospital % CBD Injury
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Use of Cholangiography in Washington State
0.00% 20.00% 40.00% 60.00% 80.00% 100.00% 10 20 30 40 50 60 70 80 90 Hospital % IOC
0.00% 5.00% 10.00% 15.00% 20.00% 25.00%
90-day mortality
SCOAP Data 2006 - 2008 Colon Resection Reoperation Rate
By Hospital, 1987-2004
0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00% 35.00% 40.00% 10 20 30 40 50 60 70 80 90 100
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SCOAP data 2009
0% 5% 10% 15% 20% 25% 30% 35% 40% SCOAP Hospitals
Pre-SCOAP ~1500 fewer reoperations
Elective Colon Resection
Testing for Leak in OR
Prevents Reoperation After OR
Avoiding Transfusion in Elective General Surgery Avoiding 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 OR Better Diabetes Management in OR
Proper Lymph Node Management in Cancer Proper 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
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
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 2009
Non-SCOAP SCOAP
$ 67.3 Million
Average Cost/Case (2009 dollars)
All SCOAP Procedures combined (35,994 patients)
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London, UK
EURO EMRO WPRO I SEARO AFRO PAHO I
Amman, Jordan Toronto, Canada New Delhi, India Manila, Philippines Ifakara, Tanzania
WPRO II
Auckland, NZ
PAHO II
Seattle, USA
Outcomes before and after Checklist
Haynes A et al. N Engl J Med 2009;360:491-9
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: Process
before and after checklist implementation
50% 60% 70% 80% 90% 100%
BB cont'd PBG checked Normothermia DVT proph Abx on time
% of elective colon/rectal cases
Q1 2008
Hospital Performance: Process
before and after checklist implementation
50% 60% 70% 80% 90% 100%
BB cont'd PBG checked Normothermia DVT proph Abx on time
% of elective colon/rectal cases
Q1 2008 Q4 2009
Hospital Performance: Process
before and after checklist implementation
50% 60% 70% 80% 90% 100%
BB cont'd PBG checked Normothermia DVT proph Abx on time
% of elective colon/rectal cases
Q1 2008 Q4 2009
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Hospital Performance: Outcomes
before and after checklist implementation
0% 2% 4% 6% 8% 10% 12%
Wound opened Reoperation CAE % of elective colon/rectal cases
Q1 2008 Q4 2009
PATIENT
DOCTOR’S OFFICE
OPERATING ROOM
PATIENT
DOCTOR’S OFFICE
OPERATING ROOM
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What is Strong for Surgery?
State-wide public health campaign
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
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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Education Surveillance and Feedback Administrative Changes Peer to peer forces Penalties Rewards
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Administration and hospital leadership Surgeons Practice Manager RNs MAs Dietitians Other office staff
Conclusion
Progress and innovation in science and medicine have outpaced quality improvements in the delivery of care Society is paying attention to the safety, efficacy and compassion with which medicine is applied There is an opportunity for surgeons to make a substantial impact in this area Such 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
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sleep
40-hr awake
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)
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)
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 loss1 Long-haul flight crews3 Obstructive 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
Effect of experimentally, medically and
“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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Focus on quality and cost-effectiveness Data Impacts behavior through:
Benchmarking Education Standard orders Checklists
PATIENT
DOCTOR’S OFFICE
OPERATING ROOM
Malnutrition is prevalent in surgical patients. Best determinant of surgical outcome. Modifiable with appropriate intervention. Immunonutrition may improve recovery.
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Link between high blood sugar levels and SSIs
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
Lancet 2012; 2279-2290 2011 US Department of Health and Human Services
> 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
Some medications and Herbal remedies ↑ risk
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
Smoking is prevalent
1/3 of all patients
Smokers have ↑ risk of complications
Pulmonary Circulatory Infectious Impaired wound healing
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Education Surveillance and Feedback Administrative Changes Peer to peer forces Penalties Rewards
DOMAINS OF BEHAVIORAL MARKS Briefing Information Sharing Inquiry Vigilance and Awareness Contingency Management
Mazzocco K, et al, Am J Surg 2009;197
strongforsurgery@becertain.org
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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 cancer Screening (WA) Detection & treatment of depression Adverse drug events Hospital acquired infections Hospitalized patients injured through negligence
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(69%)
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(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 Recommended well-child visits (WA) Treatment of Bronchitis (WA) NBA Free-throws
Sources: modified from C. Buck, GE; Dr. Sam Nussbaum, Wellpoint; Premera 2004 Quality Score Card; March of Dimes
level (% Defects)
Defects per million
∑
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Communication Quality and Surgical Morbidity
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Adjusted Odds Ratio Risk Factor Complication or Death BMRI 4.82 ASA 1.51
Clinical Trials, CER Studies Guidelines Performance Indicators Surveillance Outcomes
Education and Feedback