More than 2,100 surgical team members, clinical registry experts, and allied and administrative health care professionals attended the American College of Surgeons (ACS) 2019 Quality and Safety Conference, July 19–22 in Washington, DC. The theme of the conference, Putting Our Patients First, was evident in the conference’s seven preconference sessions, nine general sessions, and many breakout and abstract sessions, as well as the formal launch of the Geriatric Surgery Verification (GSV) Quality Improvement Program.
In his welcoming remarks, Clifford Y. Ko, MD, MS, MSHS, FACS, Director, ACS Division of Research and Optimal Patient Care, said, “This is the largest Quality and Safety Conference ever, with the largest number of sessions and most abstract submissions (approximately 600).” In fact, the conference has grown so much over the last 12 years that it now needs to take place at a conference center rather than a hotel.
Dr. Ko focused his opening remarks on value improvement in surgery, noting that the value equation is the sum of quality divided by costs. He said the denominator—quality—means more than “first, do no harm.” It is defined by “making patients better” in a way that is meaningful to them. Dr. Ko said, “Quality should be defined as care and outcomes that matter to the patient.” Using this definition, quality metrics would include not only clinical data, but also patient-reported outcomes (PROs) and patient-reported outcome measures (PROMs).
Sometimes physicians learn the importance of putting the patient first by being patients themselves. Rana Awdish, MD, FCCP, FACP, a pulmonologist and critical care physician at Henry Ford Hospital, Detroit, MI, and keynote speaker at the conference, experienced this situation when she developed a ruptured hepatic adenoma at seven months into a pregnancy.
She spoke of being rushed to the hospital and then into the operating room (OR) for an emergency cesarean section. As she was going into deep sedation, she heard the anesthesiologist say, “‘She’s circling the drain.’” When she awoke a few days later, she could hear the intensive care unit team rounding and heard the chief resident say, “‘She’s been trying to die on us.’ I felt by him saying that, he was creating an adversarial relationship,” Dr. Awdish said, revealing that she had made similar comments just days before, but it was different to hear as a patient.
“For me, that immediate transposition from critical care physician to critically ill patient exposed things to me about medicine, this field that I had revered since I was a child,” Dr. Awdish said. “There were deficits in communication, there was discoordination of care, and, at times, there was a complete lack of ability to attend to suffering. I saw us through the lens of our patients, and it frightened me.”
Dr. Awdish pulled through and recovered from hepatic and renal failure as well as a stroke thanks to the medical treatment she received, which included 26 units of blood products on the night of her collapse, five major operations, and extensive physical therapy. The experience exposed her, though, to the shortfalls in how she and her colleagues would interact with patients.
Clinicians are trained to detect and treat illness. “What we’re less well-trained to do is decode the fear our patients are experiencing,” Dr. Awdish said. At that juncture, she said, she needed “things that medicine couldn’t give”—time to be with her family, to feel supported and valued as a person. “I never understood how much illness robs our patients of their identities,” she said.
“We don’t always take the time to integrate a patient’s values and emotions into their care,” Dr. Awdish said. When she returned to active practice, Dr. Awdish wanted to reconcile being a confident, proficient physician with what she learned as a patient. She recalled previously believing that her “value came from healing, from treating illness,” but she had come to understand how “holding space for the patient’s suffering, listening to their pain was in and of itself a therapeutic act.”
“Many of us were taught in medical school that if we give of ourselves, we’ll somehow be depleted. I think it’s the opposite,” Dr. Awdish said. “These channels of active listening, of empathy, of compassion, are reciprocal. We gain more than we ever give.”
GSV standards unveiled
One ACS initiative that has been developed with the goal of attending to patients’ overall goals of care is the GSV Quality Improvement Program, which was unveiled at a reception and dinner July 18. With the support of The John A. Hartford Foundation, the GSV program was developed over a four-year period with more than 50 stakeholders and two phases of hospital site visits, culminating in the creation of 30 standards that hospitals must meet to receive ACS GSV accreditation. These standards aim to concisely address the most important aspects of surgical care for patients ages 75 and older.
“This program really has the potential to do something,” said Ronnie A. Rosenthal, MD, MS, FACS, who led the Coalition for Quality in Geriatric Surgery (CQGS) Core Development Team, which produced the GVS Standards. “This is going to be a game-changer for older Americans.”
The guest speaker at the event was Shari M. Ling, MD, Deputy Chief Medical Officer, Center for Clinical Standards and Quality, Centers for Medicare & Medicaid Services (CMS). Dr. Ling said that CMS is the largest payor for health care services in the nation and that most beneficiaries have four or five medical conditions in addition to the one treated in a single episode of care. As a result, it is important that all providers work in alignment to provide care “to all the patients we touch upon in a true and earnest way,” Dr. Ling said.
Underscoring the importance of including patients in the discussion about the care they receive, patients now serve on all CMS advisory panels “to help us understand what care looks like when they receive it to help guide us in our program and policy development,” Dr. Ling said.
Speaking of the GSV program specifically, “I’ve been personally honored to watch this work evolve,” Dr. Ling said. “Thank you for having the courage to go forward.”
The conference included a track of preconference workshops and breakout sessions on the GSV, which focused on how to become a geriatric surgery-verified center; the aging population and rising health care costs; improved geriatric outcomes; and emergency, cancer, and bariatric surgery for older adults.
PROs and quality measurement in surgery
Assessing the quality of surgery and surgeons through clinically reported metrics is vital to quality improvement, but it is equally important to think about quality from the patient’s perspective. Larissa Temple, MD, MSc, FACS, professor of surgery and chief of colorectal surgery, University of Rochester Medical Center, NY, spoke about how PROs can help improve clinical care. She noted that one study showed that collecting PROs from a group of stage IV cancer patients as they underwent treatment led to improved survival time, likely because their clinicians had a better understanding of their health status. Patient data collection can be difficult, so “we really need to make sure we’re asking the right questions, and we need to make sure we’re asking the questions that matter to the patient,” Dr. Temple said.
Improving communication with patients
Effective communication is paramount to the provision of high-quality, patient-centered care.
Heather Neuman, MD, FACS, associate professor, University of Wisconsin School of Medicine and Public Health, Madison, said patient-centered communication “considers patient needs and values, builds a strong relationship, and includes the patient in care decisions.” These variables can be measured. “Thinking through what it is you’re trying to measure and what perspective is going to be the most important is one of the first things you need to do in measuring communication,” Dr. Neuman said. She explained different methods of measurement, including patient surveys, direct observation such as audio- or video-recorded interactions, and feedback from third-party observers. Each has its strengths and weaknesses, and it can be difficult to decide which option to pursue, but “we all agree communication is important, and it is a skill that can be developed through data.”
Setting expectations before and immediately after surgery is crucial in communicating with patients and developing a positive relationship, according to Muneera Kapadia, MD, FACS, clinical associate professor, University of Iowa, Iowa City. “Setting expectations allows patients and their families to participate in shared decision making,” Dr. Kapadia said. Classically, surgeons explain to their patients all of their expertise regarding possible outcomes, but “the reality is, preoperative expectation setting is much more effective if it is done as a dialogue and not a monologue.”
Dr. Kapadia suggested using a communication model called Ask-Tell-Ask. Begin by asking a patient’s perspective about what they know about their condition; tell the patient specific technical information about their procedure while prioritizing key information and avoiding jargon; and then ask the patient again what their expectations are as a “teach-back” moment to make sure they understand what has been discussed. Ask-Tell-Ask also is useful in the postoperative setting in cases that resulted in poor outcomes, Dr. Kapadia said.
Gretchen Schwarze, MD, MPP, FACS, associate professor of surgery, University of Wisconsin-Madison, spoke about different ways to improve communication with patients. “Patients want to participate in their own care—they just don’t always know how,” Dr. Schwarze said. One method she discussed was “patient activation” before the surgical consult, which means giving patients the ability to frame and communicate their questions beforehand. Question-prompt lists, decision aids, and patient navigators are useful resources in this stage. Dr. Schwarze also stressed the importance of talking about goals and tradeoffs. “We’ve all been taught to talk about risks and benefits, but really, if you’re going to talk about whether surgery is worth it, you need to talk about what the outcome is and whether all of the things you need to go through to achieve that outcome are absolutely worth it,” Dr. Schwarze said.
Surgeons should focus on discerning the patient’s goal for the operation—“I want to be healthy and functional”—over the surgeon’s—“I want to remove this tumor efficiently.” Finally, surgeons should “attend to emotion, because once you do, you can move forward and have a rational conversation.”
Avoiding burnout, increasing resilience
Providing patient-centered care goes beyond technique and data; it begins with surgeons taking care of themselves to avoid burnout and increase resilience in a demanding field, according to Taylor Riall, MD, PhD, FACS, professor and division chief, surgical oncology, department of surgery, University of Arizona, Tucson. The consequences of burnout, including emotional exhaustion, depersonalization, and a low sense of personal achievement, affect surgeons and their colleagues, leading to career dissatisfaction, depression, substance abuse, and suicide, among other issues. “For many of us, the concept of burnout resonates poorly. It suggests failure of resourcefulness or resilience, of suffering a ‘moral injury,’” Dr. Riall said. “But the moral injury of health care is being unable to provide high-quality health care from a lack of personal care,” and surgeons must be leaders in expecting better self-care for themselves and colleagues.
Beth Frates, MD, director of wellness programming, Stroke Institute for Research and Recovery, Spaulding Rehabilitation Hospital, and clinical assistant professor, Harvard Medical School, Boston, MA, said that part of self-care begins with lifestyle medicine—a holistic approach that addresses some of the root causes of mental distress or burnout. It is based on six pillars, including exercising regularly; eating healthy foods; getting enough sleep; having strong interpersonal relationships; managing stress; and cutting down on smoking, drinking, and other unhealthy habits. “When we talk about well-being for preventing burnout, we can’t just talk about exercise, diet, or sleep,” Dr. Frates said. “We also need a peaceful mind. We need to be able to unplug and to have a peaceful heart, which is born through connecting your sense of purpose to your work.” Dr. Frates recommended stress resiliency training and one-on-one therapeutic coaching for surgeons to “allow them to be their best selves.”
Leadership in providing patient-centered care
According to Patricia L. Turner, MD, FACS, Director, ACS Division of Member Services, “leadership is a process.” Anyone within an organization can and should lead. “Effective leadership styles can be learned,” but it is important that leaders find a style that matches their personality. “It has to be authentic,” she said.
Certain behaviors can derail leadership, Dr. Turner said. Examples include lack of enthusiasm, acceptance of one’s own mediocre performance, lack of vision and direction, poor judgment, unwillingness to collaborate, inauthenticity, resistance to new ideas, repeating the same mistakes, lack of interpersonal skills, failure to develop others, and ineffective communication.
Paramount to leadership is emotional intelligence, which involves self-awareness, self-management, and social awareness or relationship management, Dr. Turner said.
At the highest level, leadership is about creating change within the organization and encouraging others to grow. “It isn’t about you anymore,” she said. “If your leadership isn’t all about you, it will live beyond you.”
Jyotirmay (Joe) Sharma, MD, FACS, FACE, associate professor, general and endocrine surgery, division of general and gastrointestinal surgery, department of surgery, Emory University School of Medicine; and director, thyroid and endocrine surgery, Emory University Hospital, Atlanta, GA, said leaders in mid-level positions need to define patient-centered health care and quality for their teams.
The hallmarks of patient-centered, quality care include efficacy, efficiency, effectiveness, optimization, acceptability, and equity, Dr. Sharma said. When leading efforts to apply these concepts within institutions, it is important to ensure that the strategic plan reflects the values of the organization and to clearly define the criteria for success, he added. Leaders should “celebrate success, establish alignment, and clear the path.”
ACS President-Elect Valerie W. Rusch, MD, FACS, said, “The top challenges in leadership arise from widely divergent opinions or an entrenched point of view.” When this scenario develops, leaders need to open people’s minds to shifting paradigms, manage their anxieties, and thwart disruptive behavior.
To respond to challenges in leadership, Dr. Rusch recommended the following actions:
- Provide good data
- Develop consensus-based solutions
- Find common ground
- Engage all interested parties
- Establish agreed-upon mechanisms and time frames for implementation
- Display patience and perseverance
To ensure patients continue to have access to high-quality care, the health care system needs transformative change, which ACS THRIVE (Transforming Health Care Resources to Increase Value and Efficiency) is designed to do. ACS THRIVE is the result of collaboration between the ACS and the Harvard Business School (HBS) Institute for Strategy and Competitiveness. THRIVE combines the knowledge the ACS has amassed in improving surgical outcomes to reduce costs with an HBS plan to create a value-based health care system. “Our goal is to deliver better care for lower care costs,” said ACS Executive Director David B. Hoyt, MD, FACS.
“One of the things the ACS brings to this discussion most is experience,” he said, through the establishment of standards-setting, accreditation, and quality improvement programs. Through these initiatives, the ACS has found that “if you encourage hospitals to analyze their data, outcomes improve,” Dr. Hoyt said.
“There are two definitions of quality,” Dr. Hoyt said: conformance quality, in which the provider hits the specifications and averts any preventable or avoidable complications; and performance quality, which means providing superior care and achieving patient goals. Moving toward performance quality will require that health care professionals “focus more on want patients want, not just what physicians think they want,” Dr. Hoyt said.
At the same time the College was developing its expanding array of Quality Programs, the HBS was developing a plan for a value-based health care delivery system, Dr. Hoyt said.
According to Frank G. Opelka, MD, FACS, Medical Director, ACS Quality and Health Policy, the U.S. needs to move to a value-based health care system because “44 states now spend more on Medicaid than K−12 education, health care spending per person is growing twice as fast as household income, and 48 million people can’t afford their prescriptions.” Furthermore, health care has shifted from a cottage industry to a complex enterprise, but physicians are still paid using the same fee-for-service model used in the 1960s. As a result, patient care has become fragmented, with multiple clinicians providing distinct services without coordination across the continuum of care, leaving the nation with “a health care system that has an unknown value, is unaffordable, and unsustainable,” he said.
Mary Witkowski, MD, MBA, fellow, HBS Institute for Strategy and Competitiveness, outlined the strategic agenda for creating a value-based health care delivery system, as follows:
- Reorganize care around patient conditions or groups of related conditions into integrated practice units covering the full cycle of care
- Measure outcomes and costs for every patient
- Move to value-based reimbursement models and, ultimately, bundled payments for conditions
- Integrate and coordinate care in multi-site care delivery systems
- Expand or affiliate across geography to reinforce excellence
- Build an enabling information technology platform
Robert Kaplan, MS, PhD, senior fellow and Marvin Brower Professor of Leadership Development, emeritus, HBS, said, “The whole health care sector is behind in measuring cost.” To modernize the system, costs should be measured across the continuum of care using time-driven activity-based costing (TDABC), Dr. Kaplan said. TDABC involves three steps, as follows:
- Determine the care process; that is, what activities are performed, who performs each activity, and how long each activity should take
- Calculate the cost per unit of time for each type of personnel and resource
- Account for consumables, such as materials, supplies, and drugs
“We find that bundled payments are ideally suited to value-based care,” Dr. Kaplan said. A value-based bundle payment should include a single, risk-adjusted payment that covers all of the care required to treat a patient’s medical condition contingent on achieving good outcomes and at a price that provides a fair margin for delivering effective and efficient care, he said.
Bruce Hall, MD, PhD, MBA, FACS, vice-president and chief quality officer, BJC Healthcare, St. Louis, MO, and consulting director, ACS National Surgical Quality Improvement Program, said value-based care is about “taking better care of our patients and communities in a more sustainable way.” In a value-based health care system, patients, their families, and advocates should expect desirable outcomes that are consistent with their goals of care; to be informed of what to expect during the course of treatment; to feel confident that appropriate care is furnished; financial transparency; and that it is a positive, respectful experience. Physicians, other health care professionals, and health care facilities should expect acknowledgments and rewards for providing high-quality care, predictable and low administrative burdens, and support and rewards for innovations. Payors should anticipate reduced costs, less cost variations, and more efficient payment processes.
The value equation
Sandra L. Wong, MD, MS, FACS, chair of surgery, Dartmouth-Hitchcock and the Geisel School of Medicine at Dartmouth, and senior vice-president, surgical service line at Dartmouth-Hitchcock, Lebanon, NH, said the goal of value-based care is to optimize quality by using the right metrics, including PROMs, while decreasing costs.
“There are problems with how we measure costs,” Dr. Wong said. ”We still live in a fee-for-service environment.” Dartmouth engaged in an eight-year experiment to determine the effects of a global, or bundled, payment system for surgical care and after a period of time began realizing savings. “I think we are making some headway in decreasing costs,” she said.
Thomas Aloia, MD, FACS, chief value and quality officer, department of value and quality; chief medical executive; and professor, department of surgical oncology, division of surgery, University of Texas MD Anderson Cancer Center, Houston, said providers and patients define value differently. “Ninety percent of providers emphasize survival, while 90 percent of patients want recovery. They want to go home,” he said.
Dr. Aloia noted that “60 percent of health care dollars are spent in the last six months of life. Stop doing things that don’t help people.” To provide care that is more meaningful to patients, he encouraged surgeons to use risk calculators for shared decision making.
Tying together the cornerstones of quality, safety, and value
The cornerstones of patient-centered, value-based care include ethical behavior, standardization, case review, and reduction of unnecessary spending.
Peter Angelos, MD, PhD, FACS, Linda Kohler Anderson Professor of Surgery; chief, endocrine surgery; and associate director, MacLean Center for Clinical Medical Ethics, University of Chicago, IL, explored the ethical dimensions of surgical care. He noted that key elements of ethical patient care include trust, communication, the surgeon-patient relationship, and shared decision making. “The surgeon-patient relationship is intensely personal. We are asking patients to trust us individually, and we have a responsibility to uphold that trust,” Dr. Angelos said.
Rachel Kelz, MD, MBA, MSCE, FACS, professor of surgery, Hospital of the University of Pennsylvania, Philadelphia, spoke on the role of standardization. A lack of standards leads to duplication, miscommunication, and ambiguity—all of which negatively affect patient care. “Standardization establishes a relationship between people and their work processes,” Dr. Kelz said. In developing standardized practices within your institution, “act with integrity, act with reason, and act as a citizen” of your community, she added.
“Case outcomes are an indicator of structure or process,” noted Michael Chang, MD, FACS, chief medical officer, USA Health, and associate vice-president for medical affairs and professor of surgery, University of South Alabama College of Medicine, Mobile. Consequently, “Case review is foundational to any surgical performance improvement program.” Dr. Chang noted that the ACS Red Book, Optimal Resources for Surgical Quality and Safety, describes the process for both single-discipline and multidisciplinary case review. “After case review, act on a single case or trend,” he said.
Martin Makary, MD, MPH, FACS, chief, islet transplant surgery, and professor of surgery, Johns Hopkins Medicine, Baltimore, MD, noted that “24 percent of Americans avoid care because of fear of medical bills.” He said a significant driver of high costs in health care is the “middlemen,” including group purchasing organizations and pharmacy benefit managers. Health care institutions and other providers that use these entities must “pay to play,” and often are asked to give these groups exclusivity, enabling them to set prices that are higher than if the resources were purchased directly from the manufacturer, thereby driving up costs, which are then passed on to patients.
Inappropriate care is another factor that adds to health care cost, Dr. Makary said. In fact, physicians say 21 percent of care is unnecessary. “The opioid crisis is a manifestation of the crisis of inappropriateness,” he added.
Continued developments in the opioid epidemic
Opiate abuse and misuse continues to be a topic of concern in the health care community, with more than 100 people in the U.S. dying from overdoses each day. Because opioid prescriptions given at postoperative discharge create a significant risk factor for chronic opioid use one year later, it continues to be incumbent upon the surgical community to act responsibly.
Jennifer Waljee, MD, FACS, associate professor of plastic surgery, University of Michigan, Ann Arbor, said up to 80 percent of opioids prescribed postoperatively go unused and are at risk of being diverted into the community—and unlike in primary care or emergency medicine, data show that opioid prescriptions by surgeons actually increased from 2010 to 2016. Through the Michigan Opioid Prescribing Engagement Network (OPEN) surgeons and other health care providers partnered to “get data, guide change, and collaborate on best practice guidelines,” Dr. Waljee said. They found that when 30–50 pills were prescribed postoperatively, only six were used on average, leaving many at risk for potential diversion. Since OPEN created new prescribing guidelines that lowered the number of given pills, “we have never seen any increase in calls for refills, no change in patient-reported pain, and when patients are prescribed fewer pills, they take fewer pills,” Dr. Waljee said. In fact, Michigan hospitals have experienced an approximately 50 percent decrease in prescribed pills while maintaining patient satisfaction after implementing the guidelines.
Other opioid initiatives are finding success across the country. Jonah Stulberg, MD, PhD, MPH, FACS, assistant professor of surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, provided an update on the work he and his colleagues at the Illinois Surgical Quality Improvement Program are doing with the Minimizing Opioid Prescribing in Surgery (MOPiS) program. Although MOPiS has resulted in fewer opioid prescriptions, “Where we still seem to be failing is in addressing this culture of pain we’ve developed over decades,” Dr. Stulberg said. He said that if the principles curated through MOPiS were applied to all procedures and across all specialties, a natural institutional culture shift in opioid prescribing patterns would emerge.
“We need to recognize that there are multiple dimensions to how our patients experience pain,” said Zara Cooper, MD, MSc, FACS, trauma surgeon and Kessler Director, Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA, speaking on the use of opiates in palliative care. Pain for patients in palliative care can be physical, psychological, social, or spiritual, Dr. Cooper said. Unfortunately, “too often, we try to treat all of them with opiates.” She suggested that surgeons and surgical teams think more broadly about the problem. To address the opioid crisis, surgeons need to employ a multimodal approach, not only with nonopioid medication, but with strong patient communication and attendance to emotional needs.
The 2020 ACS Quality and Safety Conference will take place July 24–27 in Minneapolis, MN.