Leadership conference focuses on outcomes data and surgeon engagement

Members of the American College of Surgeons (ACS) from across the nation and across the surgical specialties converged on Washington, DC, March 25–March 26, for the 2012 Leadership Conference.

“Surgical leadership for quality and safety” was the theme of this year’s conference, which featured separate, concurrent sessions for young surgeons, residents, chapter leaders, and chapter executives (administrators and executive directors).

The meeting took place at the JW Marriott in the nation’s capital and drew a total of 184 attendees. Members of the College’s Young Fellows Association developed and moderated the Leadership Conference, which preceded the ACS’s inaugural Advocacy Summit (see page 32 for the Advocacy Summit wrap-up).

Taking action

ACS President Patricia J. Numann, MD, FACS, welcomed attendees to both the Leadership Conference and the Advocacy Summit in her opening remarks by highlighting the College’s unparalleled commitment to quality care. “The College is entering its 100th year, and all of the programs we have are incredible. The College has always been at the forefront of ensuring that we give good, quality care,” said Dr. Numann.

She urged attendees to “shape their own future” instead of “waiting for outside agencies to shape it for you. It takes courage not to sit in your office and question what is going on with health care, but to stand up and say what you believe,” said Dr. Numann, referring to the Advocacy Summit and visits scheduled on Capitol Hill the next day.

ACS NSQIP promotes teamwork

J. Michael Henderson, MB, CHB, FACS, chief quality officer of the Cleveland Clinic; and Barbara L. Bass, MD, FACS, John F. and Carolyn Bookout Distinguished Endowed Chair and Director, Methodist Institute for Technology, Innovation, and Education, Houston, TX, participated in a panel discussion on the ACS National Surgical Quality Improvement Program (ACS NSQIP®). They addressed how ACS NSQIP outcomes data may be used to promote teamwork as a means toward delivering quality care.

According to Dr. Henderson, four main characteristics distinguish ACS NSQIP data from the information used in other quality improvement (QI) programs. ACS NSQIP data are:

  • Clinical data (not administrative and claims data)
  • Risk-adjusted
  • Case-mix adjusted
  • Patients are tracked patients from pre-operation though 30 days post-operation

“The 30-day patient follow-up is a unique feature for ACS NSQIP, and is a critical component of this program,” said Dr. Henderson.

As of March 2012, a total of 440 hospitals were enrolled in the ACS NSQIP program, which Dr. Henderson called “significant growth,” but said the numbers were still relatively small when compared with other medical registries.

He said QI programs at their core are about “preventing complications, saving lives, and reducing costs. Most hospitals improve over time and bring value. The literature shows that quality does improve with this program,” he said, citing an article published in the September 2009 issue of Annals of Surgery titled “Does surgical quality improve in the American College of Surgeons National Surgical Quality Improvement Program?: An evaluation of all participating hospitals.”

One of the primary costs involved in running QI programs is hiring a full-time nurse or coordinator to collect the data, Dr. Henderson said. “So, I suppose it all depends on where you are as a hospital. Are you constantly scrambling to get things done, or are you able to commit to this program? If you’re not going to use the data—it might not be worth it,” said Dr. Henderson, who also emphasized ACS NSQIP’s flexibility with participation options for virtually every hospital size and type, including:

  • Classic
  • Essential
  • Small and rural
  • Targeted
  • Pediatric (The ACS NSQIP Pediatric program is the first and only nationally benchmarked, risk-adjusted, clinical outcomes-based program for pediatric surgery in the nation.)

Measures option

“Over the next decade, how hospitals are improving will be more important than what their overall absolute scores are,” added Dr. Henderson. “This [program] is a great opportunity because it provides good data. The College needs to be commended for its efforts, but remember, success depends on us and our involvement. There is no question in my mind that this is the right thing to do.”

“If surgeons view [ACS NSQIP] as their program—they will want to use it,” said Dr. Bass during her presentation. “We all need to be ‘crusaders’ of NSQIP, as Dr. Henderson said, and persuade our colleagues of the credibility of the program.” Dr. Bass underscored the importance of surgeon engagement as a key to successful QI programs by offering the following suggestions:

  • Offer surgeons actionable data about their own practices
  • Encourage crusaders/supporters of the initiative
  • Obtain the support of information technology staff and the quality infrastructure (including the leverage power of surgeons)

At The Methodist Hospital System, Houston, the facility follows specific QI goals, such as being patient-centered, effective, safe, timely, efficient, and value-driven. “These goals are the same at any hospital,” said Dr. Bass. “Making [these goals] public can only enhance the reputation of your institution in what is a very competitive market.”

A key challenge to successfully implementing a QI program is actually “putting the data to work,” added Dr. Bass. “The big question is: How do you convert data to quality improvement processes—especially if you fall in the middle range? You’re not great, but you’re not terrible, either.” She suggested addressing lower-hanging fruit first, by:

  • Identifying systemic problem areas
  • Identifying high-risk groups
  • Applying best practices to those cohorts

Examining provider- or site-specific reports is another way to use data to foster surgeon engagement with QI programs. According to Dr. Bass, these reports help in the following key areas:

  • Inform and engage the surgeons in QI process (surgeons care about their work)
  • Inform and engage surgeons in the new era of quality transparency (surgeon protection)
  • Improve quality of care (lack of data can mean no action taken)
  • Allow surgeons to compare their work with others’ (including local and national outcomes data)

“To prepare surgeons for 2017, we want surgeons to know their own results,” explained Dr. Bass. “This is important for the surgeon protection process. This is all going to be public in 2017, so we might as well be proactive and become aware of this now. ACS NSQIP is the only program that offers individual surgeons their data,” she said.

Developing leaders

The QI Leadership Skills panel—composed of John Handy, MD, FACS, Providence Health System, Portland, OR; Deborah J. Baker, DNP, CRNP, director of nursing, Johns Hopkins Hospital Department of Surgery, Baltimore, MD; and Thomas Genuit, MD, FACS, University of Maryland Medical Center, Baltimore, MD—stressed the importance of strong leadership and effective communication to promote quality and safety initiatives.

Dr. Handy addressed the challenges in developing a multidisciplinary approach to quality and safety at both an individual institution and throughout a hospital system at the regional level. According to Dr. Handy, the benefits of multidisciplinary care include:

  • Improved staging
  • Shorter time to therapy
  • Increased rates of surgery
  • Increased quality of surgery
  • Increased compliance with established guidelines
  • Increased protocol accrual
  • Improved care of non-cancer co-morbidities
  • Improved overall and progression-free survival

“The word ‘quality’ is a hard word to get your head around,” noted Dr. Handy, who said he defines quality as “structure plus processes plus outcomes equal quality.”

Through his work with the Providence Thoracic Surgery Initiative, Dr. Handy has determined some essential traits of a surgical leader, including:

  • Authoritative reputation (at the local, regional, and national level)
  • Expertise (practice-based, lifelong learning)
  • Ability to communicate vision to team, leadership, colleagues
  • Willingness to let others shine

“Let others shine—if it’s just about you, it won’t work. It’s not just about surgeons; it’s about the team,” explained Dr. Handy, who also advised surgical leaders to meet frequently with their teams to ensure successful implementation of a multidisciplinary approach to QI.

Ms. Baker provided the perspective of “frontline staff” and patients in developing effective, quality-driven teamwork. “We take a triad approach to quality improvement,” explained Ms. Baker. “And like the shape of a triangle, each component is equally important.” Her guidelines for improving patient safety include:

  • Leadership engagement
  • Comprehensive Unit-Based Safety Programs (CUSP) Culture, which empowers staff to assume responsibility for safety in their environment
  • Patient- and family-centered care, which allows for greater accountability for health maintenance by patients and families

“You have to develop leaders—they don’t just happen,” added Ms. Baker. “To do this, you have to ‘build your bench,’ and this goes for nurses and physicians.” According to Ms. Baker, building a bench includes the following steps:

  • Identify and expand on an individual’s strengths, minimize weakness
  • Encourage staff to speak up and reward this behavior
  • Provide feedback
  • Ensure interprofessional team training
  • Promote multidisciplinary problem solving

In his presentation, Dr. Genuit highlighted the challenges of implementing quality improvement measures in a teaching hospital. “Creating effective means of communication” and supporting a “universal language around outcomes and QI” are paramount steps to launching a successful program at a teaching facility, according to Dr. Genuit, as are generating interest and involvement from residents, students, and “mid-level providers,” not to mention both full-time and private faculty.

Residents in particular face many competing demands, such as acquiring medical knowledge and mastering technical skills, fulfilling scholarship requirements, and maintaining work-life balance. “Traditionally, residents are not involved in long-term, hospital-wide quality initiatives,” said Dr. Genuit. “But incentives almost always work, such as a QI award to a resident that might involve additional training at a national conference. This is something we are seriously considering.” In addition to incentives, Dr. Genuit offered other suggestions for generating resident and midlevel provider engagement in QI programs, including:

  • Changing the scope of morbidity and mortality conferences
  • Offering opportunities for involvement in hospital-wide committees
  • Establishing a resident committee
  • Including formalized QI/outcomes evaluation education

At Dr. Genuit’s facility, 15 residents currently are involved in 11 committees and have participated in more than eight ongoing QI projects.

“It is our hope that these efforts will lead to the development of a culture of quality improvement, anchored in the mission and vision of the departments and of the institution, based on a universally understood language of processes and outcomes. This is an ongoing and sustainable process,” said Dr. Genuit.

Characteristics of a strong leader

David R. Flum, MD, MPH, FACS, director of the University of Washington’s Surgical Outcomes Research Center, Seattle—a multidisciplinary research center that supports outcomes research to improve the quality of surgical care—presented the conference’s keynote address. Dr. Flum focused on the effective traits of leaders.

“Leaders aren’t born—they are molded,” said Dr. Flum. “And leaders are doers. Like Dr. Numann said, it’s very easy to have opinions about doing things, but taking action is something else entirely. There is a special place for people who complain about the health care system but do nothing to change that system; it’s called the doctors’ lounge,” said Dr. Flum.

Dr. Flum revealed five characteristics of successful leaders, which he discovered after reading The Corner Office: Indispensable and Unexpected Lessons from CEOs on How to Lead and Succeed, which features interviews with top leaders from various fields and industries. Those traits include the following:

  • Passionate curiosity
  • Battle-hardened confidence (many were at one time seen as horrible public failures, but they learned to “fail-forward” and were able to learn from their mistakes and move on to new challenges)
  • Team smarts (the ability to get people to work together)
  • Simple mind-set (distill complex information and establish a common vision)
  • Fearlessness (look for opportunity even when things are not broken)

Successful leaders take action, said Dr. Flum, and they recognize truths, specifically toxic variability. “I see this truth—surgery has an existential threat when it comes to variability,” said Dr. Flum. “How it tracks it, how it controls it, and how it handles those on either side of the variability charts.”

Before implementation of the Surgical Care and Outcomes Assessment Program (SCOAP)—a physician-led, voluntary collaborative that uses aviation as a model to track and develop surgical quality—Washington State had what Dr. Flum called a very disturbing variability rate. “Prior to SCOAP there was no system in place that was providing information to hospitals and clinicians to help them understand what their care looked like compared to other hospitals and whether the care they were providing was meeting best-practice standards,” said Dr. Flum.

In addition to recognizing truths, strong leaders “search for opportunity, as shifting risk compels us to address variability,” according to Dr. Flum. He also encouraged leaders to “operationalize optimism by creating communities to change behavior,” and to not hesitate to “drive the bus” as long as they did so “with class.”

Legal pitfalls and financial skills

During a session titled How to Avoid Legal Pitfalls, Paula Cozzi Goedert, Esq., Barnes & Thornburg, LLP, Chicago, IL, provided an overview of legal considerations specifically geared toward chapter leaders. Ms. Goedert, the College’s legal counsel, covered the basics regarding chapter leaders’ fiduciary responsibilities, the legal and tax benefits of incorporation, concerns about intellectual property rights, and chapters’ insurance needs.

Jim Dowden, Executive Director of the Southern California Chapter in El Segundo, CA, and Samantha Katzbeck, CPA, ACS Controller, Chicago, IL, led a session titled Financial Skills for Chapter Leaders. This session addressed sources of non-dues revenues that can be used to support chapters’ education missions. In addition, chapters’ financial statements, auditing procedures, and long-term savings were covered during the session.

Town hall meeting

As in years past, this year’s Leadership Conference ended with a town hall meeting featuring the following ACS leaders: John H. Armstrong, MD, FACS, Chair, ACS Professional Association-SurgeonsPAC, Tampa, FL; David B. Hoyt, MD, FACS, ACS Executive Director, Chicago, IL; Dr. Numann; J. David Richardson, MD, FACS, Chair, Board of Regents, Louisville, KY; Christian Shalgian, Director, ACS Division of Advocacy and Health Policy, Washington, DC; and Andrew L. Warshaw, MD, FACS, ACS Treasurer and Chair, Health Policy and Advocacy Group, Boston, MA. Each of the panelists underscored the relevance of the theme of the conference, “surgical leadership for quality and safety,” and offered their support of the College’s ongoing advocacy and quality initiative efforts.

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