“Never forget that the numbers we talk about are people,” said Clifford Y. Ko, MD, MS, MSHS, FACS, FASCRS, Director of the American College of Surgeons (ACS) Division of Research and Optimal Patient Care and the National Surgical Quality Improvement Program (ACS NSQIP®), in introducing the theme of the ACS NSQIP 10th National Conference: Patient-Centered Care (PCC). According to Dr. Ko, more than 1,400 participants were at the 10th Annual National Conference July 25−28 at the Hilton Chicago, IL—the highest attendance to date for an event that continues to grow annually.
“We are living in a millennial environment in which we have information at our fingertips,” Dr. Ko said. “What we lose with all this information is context,” he said. “We don’t know how the concepts work in the hospital. We lose perspective. We need to know what to do when our steps don’t work.
“Quality improvement is not that easy,” Dr. Ko added. “But at this meeting, we can tell our stories and talk about our experiences. We can talk about the infrastructure needed to achieve quality, safety, and reliability. Through quality improvement success stories, we can talk about how we got there.” Practitioners must ask the pertinent questions about PCC, he said: What are its fundamental characteristics? How are interactions measured? How do we promote it?
Dr. Ko highlighted ACS NSQIP’s major accomplishments of the last 10 years, including the fact that an increasing number of hospitals are recognizing the benefits of participation. When the program launched in 2004, 18 hospitals had agreed to participate in ACS NSQIP. Today, the program is in nearly 700 hospitals worldwide.
Moreover, “We set a bar for data rigor and accuracy,” Dr. Ko said. “We’ve expanded the clinical database and advanced knowledge about achieving quality. Using clinical data, we’ve measured outcomes and influenced legislative policy.” For example, he noted that the legislation that repealed the sustainable growth rate Medicare payment formula replaces that flawed methodology with a Merit-Based Incentive Payment System.
Perhaps most importantly, “What we have observed is that if you use accurate data and make standardization and innovation a part of your culture, you can improve health care outcomes,” Dr. Ko said. Because ACS NSQIP has had a positive effect on patient care, he noted, The Joint Commission and the National Quality Forum honored the program with the John M. Eisenberg Patient Safety and Quality Award, which recognizes the major achievements of individuals and organizations in advancing patient safety and quality of care.
Putting the patient first
“Is the patient really first in your organization?” asked Scott J. Ellner, DO, MPH, FACS, director of surgical quality, Saint Francis Hospital and Medical Center, Hartford, CT; assistant professor of surgery, University of Connecticut School of Medicine; and co-chair, ACS Connecticut Chapter Committee on Patient Safety. Following up on Dr. Ko’s remarks about PCC, Dr. Ellner, who assumed an essential role in planning and organizing this year’s conference, noted that patient safety is more than a concept—it is a discipline that must be applied in daily practice.
He told conference attendees a personal anecdote of a surgical “never event”—a mistake that is never supposed to happen. “I had talked to the patient about possible complications, but despite all our talk, she had a terrible complication, and I had to have that never event conversation with her husband.
“Surgeons have to recognize that we are fallible,” Dr. Ellner added. “We will make mistakes, but what’s important is how we respond to those mistakes. Don’t get defensive. Just be very candid with family members.” The experience taught him three lessons: (1) the best patient is an empowered patient; (2) the surgeon should share decision making with the patient and family and have a frank discussion about the plan of action; and (3) the surgeon should set meaningful expectations for the patient and family.
In a session on Verifying Your Quality, moderated by Dr. Ko, ACS Executive Director David B. Hoyt, MD, FACS, said that measuring quality is the future of medicine. “It’s very exciting to see the growth of interest in quality over the past five years,” he said. “The question becomes ‘How do we take all of this information and go to the next level?’” Dr. Hoyt noted that the ACS is in the process of developing a consensus-based document on surgical quality. “We decided that what we need is a companion piece for ACS NSQIP, which has written the book on quality health care.”
Dr. Hoyt acknowledged the work of the surgical clinical representatives and noted that external peer review is critical to the quality improvement process. Health care practitioners must engage in self-assessment and honestly determine whether they are living up to the standards. The goal, Dr. Hoyt said, is high-value, highly reliable care, and the question for all practitioners becomes, “How do we harness the best practices out there?”
He also urged surgeons to work with hospital administrators. “This is a tremendous opportunity for all of us to commit to a set of standards,” Dr. Hoyt said.
“Surgeons need to confront errors and learn from mistakes. That is the lesson of [Ernest] Codman, [MD, FACS,] who promoted the idea of case review and attention to outcomes,” Dr. Hoyt added. “There must be personal accountability.” Changing a hospital culture is a slow, deliberate process that requires input from every member of the team. “The person who yells the loudest shouldn’t set the policy,” he said. The keys to success, according to Dr. Hoyt, are surgeon leadership, discipline in following explicitly defined processes, and evidence-based responses to the question, “Does it work?”
In her presentation, Quality Leadership: From Bedside to the Board, Susan D. Moffatt-Bruce, MD, PhD, FACS, chief quality and patient officer, associate dean of clinical affairs, quality and patient safety, associate professor of surgery, the Ohio State University, noted that the value of health care equals quality over cost. “The number of quality metrics imposed by the CMS [Centers for Medicare & Medicaid Services] will continue to increase, and the surgical quality officer [SQO] has to lead the transformation.” The SQO, she said, must establish a governance structure to lead surgical and safety efforts, establish mechanisms to improve surgical quality, and seek out best practice models and quality improvement techniques. What the SQO inevitably finds, she said, is resistance to change, either from the group or individuals within the group. Meet this resistance, she urged the audience, by noting that progress is impossible without change. “Change requires proven leadership, a compelling vision, and a sense of accountability,” Dr. Moffatt-Bruce said. She distinguished between a manager and a leader. A manager, she said, focuses on the present and strives to maintain the status quo and stability. A leader focuses on the future. A manager implements policies and procedures. A leader initiates goals and strategies.
“SQOs assume a vital leadership role in value-driven health care. They are the change agents,” she said. “The SQO helps the staff and patients move from volume to value. It requires some tough conversations and some tough decisions.”
In a session on Using Stories and Personal Perspectives to Change Surgery, John Wieland, MD, FACS, director of trauma, and chair, department of surgery, Order of Saint Francis St. Joseph Medical Center, Bloomington, IL, said, “Leadership is about inspiring people and motivating them to work toward organizational goals. Problems can be viewed as opportunities, but in order for this to happen, leaders must be flexible.” Mutual respect and communication between patient and surgeon are vital, he said.
“Communicate and know the hearts and minds of your colleagues,” Dr. Wieland added, noting that the goal of the surgeon leader is to create a movement that is both optimistic and centered on the patient.
In a discussion of professionalism and surgical innovation, Peter Angelos, MD, FACS, Linda Kohler Anderson Professor of Surgery, and chief, endocrine surgery, University of Chicago Medical Center, IL, pointed out the unique ethical challenges involved with surgical innovation. “Innovation is both the key to surgical progress and the greatest challenge to professionalism in surgery,” he said, noting the difference between innovation in surgery and in business. Surgical innovations, he said, may lead to breakthroughs, but they may add an element of risk to the patient’s life. Today’s surgical standards, he said, are the result of oversight by surgical colleagues and professional self-regulation.
The patient’s perspective
In line with the theme of PCC, the conference featured keynote speaker and best-selling author Marcus Engel, MS, author of The Other End of the Stethoscope, who captured the struggle of a patient who endured two years of rehabilitation and more than 300 hours of reconstructive facial surgery.
“I grew up in a suburb of St. Louis [MO] called Ferguson,” Mr. Engel said. “I have nothing but fond memories of growing up in a small-town environment. I lived a very normal existence.” That sense of normality, however, was turned upside-down one weekend shortly after he started college. He and a group of friends piled into a small Toyota to attend a St. Louis Blues hockey game. On the way home from the game, his life changed instantly when the car was broadsided in a busy intersection by a drunk driver going twice the posted speed limit. Only a thin piece of metal in the automobile separated him from the full impact of the oncoming vehicle. The horrific collision left him blinded.
“I went into shock,” Mr. Engel told the gathering. “Shock is a gift when the human body experiences something so bad. My face was crushed, and my left jaw was hanging out my side.” The paramedics stabilized him and transported him to Barnes Jewish Hospital, St. Louis.
“My memories of that first night in the ER are sketchy,” he said. Supported by a feeding tube and respirator, Mr. Engel recalls that someone was holding his right hand. “This voice said to me, ‘Marcus, my name is Jennifer. You were in a car accident, and you are in the hospital.’ Then she said the two most compassionate words that a human being can speak—‘I’m here.’”
“Jennifer,” he told the gathering, provided the “power of presence. Jennifer just knew that what a human being needed was presence.” One day, two ophthalmologists came to Mr. Engel’s bedside and gently told him that they would be unable to restore his vision. “‘There’s nothing we or you can do to save even a portion of your vision,’” they told him.
“Hurting people hurt other people, and I remember telling them that I hated them,” Mr. Engel said. “Don’t you think those two surgeons felt as bad about this as I did? I remember asking them if there was a drug I could take that would restore my vision. Finally, I remember asking, ‘Why me?’”
He recalled a nurse named Barb. “‘I get to take care of you for the next eight hours,’” she said. “She asked what I preferred to be called, Marcus or Marc. She treated me like a person, not a diagnosis. That’s what I would remind all of you: You get to carry on the legacy and care for the people behind the evidence and the surveys. The profession of medicine is sacred work, and you need to remind yourselves of that every day.”
In a preconference session, How to Be an Effective Communicator, Dr. Ellner offered advice on how to approach a difficult conversation with another member of the surgical team. “It’s important not to attack the person. Reframe the conversation so that it is not a personal issue, but get to the bottom of the issue, and when you are done, there should be mutual understanding of how to move forward.”
At the same session, Marlies van Dijk, RN, MSc, provincial implementation lead, innovation/quality and health care improvement, Alberta Health Services, Calgary, offered advice on speaking in front of a group of people. It’s not what you say, she told the attendees. It’s how you say it. Be mindful of your body language, she advised. Move around. Don’t stand behind a podium. Open your chest and arms and keep your back straight. Vary your hand gestures. Pause. Breathe slowly. Be confident about your message. Think about what action you want the audience to take, she said. Begin with something that will grab their attention, such as a dramatic story or a compelling fact.
The new surgeon champion: What now?
In a session titled I’m a New Surgeon Champion: Now What?, Jyotirmay Sharma, MD, FACS, assistant professor of general and endocrine surgery, Emory Healthcare, Atlanta, GA, said, “The first thing that happens is that you review the semiannual report. Then you have to decide what to do with the information.”
As the surgeon champion, Dr. Sharma and his team reviewed the hospital’s patient care in totality, from preoperative visits and perioperative counseling to intraoperative issues and postoperative care, and focused first on surgical site infections (SSIs). They collected outcomes data, fed it into the ACS NSQIP database, and extracted areas in need of attention.
The hospital administrators at Emory Healthcare initiated a new protocol for wound infection prevention, which included improved compliance with antibiotic redosing, wound protectors, chlorhexidine preparation, closing pans, double gloves, and standardization of procedures. The hospital experienced considerable improvements in SSI rates. “Failure is part of the process,” Dr. Sharma said. “Quality improvement takes time, so don’t go for the biggest thing first. Start smaller, and make it a launching pad for bigger changes.” Continue to reassure the people involved that problems are driven by the system, not individuals, he added. When successes occur, celebrate them.
The hospital culture is critical to the success of quality improvement, said Eric Skarsgard, MD, FACS. Dr. Skarsgard is professor and co-director, Centre for Surgical Research, department of surgery, University of British Columbia, and surgeon-in-chief, British Columbia Children’s Hospital, Vancouver.
“Engage your team and your clinical leaders and perioperative program managers,” he said. “Quality safety programs do not exist without the support of the surgical clinical representatives.”
And “be prepared for skepticism,” Dr. Skarsgard added. “It’s important to instill in surgeons the sense that [quality improvement] is a team sport, and you should focus on the performance of the division and on group improvement. The conversation will change.”
Dr. Skarsgard presented a Top 5 list for change using ACS NSQIP data. First, he said, the culture must be supportive. Second, the team must see the evidence that shows change is needed. Third, there must be mutual respect among all team members, and fourth, a sense of continuous improvement. Finally, all of the activities should be patient-focused.
Matthew M. Hutter, MD, MPH, FACS, spoke on continuous quality improvement (CQI), in a presentation titled 13 Years as a Surgeon Champion and Still Learning. “It’s a marathon, not a sprint,” Dr. Hutter said. “Know the data and how it is collected.” Expect to hear some surgeons protest that their patients are sicker than those reflected in ACS NSQIP data, he said. “You must remind them that NSQIP data is clinical, prospective, and risk-adjusted.”
Dr. Hutter offered several QI tips. “Work closely and meet regularly with the surgical clinical representatives,” he said. In addition, he suggested making sure that hospital administrators are not just aware of your position as surgeon champion but that they respect it. The surgeon champion must ensure that the necessary team and infrastructure are in place, and transparency must be a goal at every level. “The surgeon needs to be proactive and take ownership of changes,” he said. “Understand the data and monitor it continually.”
ACS: Commitment to quality
In a general session intended to provide updates on the ACS and quality improvement, Dr. Hoyt reviewed recent reforms in U.S. health care, noting that the Affordable Care Act has expanded access and significantly changed the payment model. Acknowledging the work of economist and researcher Michael Porter, PhD, Bishop William Lawrence University Professor, Harvard Business School, Boston, Dr. Hoyt noted that improvement in any field requires measuring results, that systems improve by tracking progress over time, and comparing their performance to that of peers inside and outside the organization. “If you measure performance and publish quality reports, you will drive the marketplace,” Dr. Hoyt told the gathering.
At a session titled Facilitating the Key Aspects of a Collaborative, moderated by Karl Y. Bilimoria, MD, FACS, associate professor, surgery-surgical services and medical social sciences, department of surgery, Feinberg School of Medicine, Northwestern University, Chicago, several speakers representing health care collaboratives revealed the lessons learned by working as teams to improve surgical outcomes. Julie K. Johnson, MSPH, PhD, professor in surgery, Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University, spoke of the how and the why of collaborative hospital site visits. “Go to gemba,” she said, referring to the Japanese term for going to the shop floor. “We learned from our site visits what people are doing when we go to the places where they work,” she said. “That’s where people are the most comfortable talking about their work.”
Joseph B. Cofer, MD, FACS, a leader of the Tennessee Surgical Quality Collaborative (TSQC) and a Past-President of the ACS Tennessee Chapter, told attendees to consider their motivation for working with a collaborative. The TSQC, established in 2008, unites the state’s surgeons, hospitals, and insurers, to share data, compare results, and improve outcomes. “This is not about getting ahead of the competition. It is about improving surgical outcomes everywhere,” Dr. Cofer said. “It takes time, and it demands staying power.”
ACS NSQIP brings a measurable, reliable path of change to an expensive, overburdened health care system. Quality improvement is slow and deliberate. It requires disciplined leaders and surgeon champions, dedicated team members, and collaboratives that work together to promote quality care and the goals of continuous quality improvement.
“Every conversation we have to improve patient care should be data driven,” said Bruce L. Hall, MD, PhD, MBA, FACS, professor of surgery, Washington University in St. Louis; vice-president of quality at Barnes Jewish Hospitals; and ACS NSQIP Consulting Director. “Accurate data are one of the strongest change agents we have.”