strategies for improving surgical quality: a conceptual framework justin b. dimick, md, mph...

Strategies for improving surgical quality: A conceptual framework

Justin B. Dimick, MD, MPHAssociate Professor of SurgeryDepartment of SurgeryUniversity of Michigan

My clinical trajectory

Disclosure•Co-Founder, consultant, and equity owner•Database/reporting software for MSQC, MTQIP, MUSIC, MSSIC, MVC, American Hernia Society, American Association of Endocrine Surgeons•No cost contract for all services related to MBSC

Performance varies

Waves of ChangeHealth System Strategic Activity

Physician AlignmentHealth systems acquiring practices, hospitalsPhysician selection – volume, quality, costFinancial incentives/compensation aligned

At-Risk Business ModelsQuality Bonuses and PenaltiesEpisode Payment BundlesAccountable care organizations

Physician-led Quality ImprovementOutcomes measurement & analysisPhysician collaboration on best practices & CDSReduced variation in quality

Act

ivit

y

My clinical trajectoryIs this a Is this a safety safety

problem?problem?

Safety of bariatric surgery in the United States

Dimick JB, et al. JAMA 2013

0.00

0.01

0.02

0.03

0.04

0.05

0.06

0.07

0.08

0.09

Non-Medicare Medicare

Ser

iou

s C

omp

lica

tion

Rat

e

Time (Year)

2004 2005 2006 2007 2008 2009

My clinical trajectory

Bariatric surgery outcomes in Michigan:Mortality = 1/3000 (0.003%)Leak rate = 5/1000 (0.5%)Bleeding = 1/100 (1.0%)Length of stay = 2 days (median)

What are the different strategies What are the different strategies for improving surgical quality? for improving surgical quality?

The next 40 minutes

• Build a shared mental model

• Introduce a conceptual framework outlining the key strategies for improving surgical quality

• Exercise & sorting of audience

• Show examples of outcomes research that uses each strategy

Exercise

• Cards will be passed from the front of the room – take 1 card and pass the deck back

• Exchange them among yourselves until you one that best represents YOU

• Sit back down sorted by color group (seating chart on next page)

Sort yourselves

YELLOWYELLOW

REDRED

GREENGREEN

BLUEBLUE

Collaborate Create

CompeteControl

Collaborate Create

CompeteControl

Innovative“Out of the box” thinkers

Focus on ideas

Collaborate Create

CompeteControl

Innovative“Out of the box” thinkers

Focus on ideas

Warm and cuddlyStrong mentoring skills

Focus on relationships

Collaborate Create

CompeteControl

Innovative“Out of the box” thinkers

Focus on ideas

DrivenCompetitive“Must win” attitude

Focus on results

Warm and cuddlyStrong mentoring skills

Focus on relationships

Collaborate Create

CompeteControl

Innovative“Out of the box” thinkers

Focus on ideas

DrivenCompetitive“Must win” attitude

Focus on results

Warm and cuddlyStrong mentoring skills

Focus on relationships

Rules and regulationsPolicy adherence

Focus on compliance

Collaborate Create

CompeteControl

Collaborate Create

CompeteControl

New technology & Innovative surgical approaches

Focus on new ideas

Physicians competing with each other

Focus on the best outcomes

Physicians working together

Focus on building relationships

Policies mandating physician compliance

Focus on compliance with standards

Improving quality = adding value

Brainstorm

• What are the best ways to improve surgical quality by focusing on competition?

Create

Compete

CMS national coverage decision

Complications with bariatric surgery in Michigan

Birkmeyer NJO et al., JAMA, 2010

COEs vs. non-COEs, 12 large States

Adverse outcomes

 Odds Ratio for Adverse Outcome,

COE vs. non-COE (95% CI) Adjusting for patient characteristics,

procedure type, and time trends (95% CI)

Any complications 0.97 (0.90,1.06)Serious complications 0.92 (0.85,1.01)

Reoperations 1.11 (0.92,1.34)

Dimick JB, et al. JAMA 2013

Implementation of the COE policy

0.00

0.01

0.02

0.03

0.04

0.05

0.06

0.07

0.08

0.09

Non-Medicare Medicare

National Coverage Decision

Ser

iou

s C

omp

licat

ion

Rat

e

Time (Year)

2004 2005 2006 2007 2008 2009

Dimick JB, et al. JAMA 2013

Challenges of using competition

• Sometimes hard to know who’s “the best”

• Patient access issues

• Highly polarizing

With competition there is tension with collaboration

Brainstorm

• What are the best ways to improve surgical quality using innovation and new ideas?

Create

Lower risk procedures

0%

10%

20%

30%

40%

50%

60%

70%

2004 2005 2006 2007 2008 2009

LRYGB ORYGB LAGB Other

NCD

Procedure type:

Time (Year)

% o

f P

atie

nts

Changes in procedure use

New technology

Band erosion rates of 30% and removal rates of 50%

Downsides of new technology

• Unintended consequences– Safer but less effective?

• Widespread adoption without adequate evidence

With innovation there is tension with standardization

1. Beaumont Grosse Pointe2. Borgess Medical Center3. Bronson Medical Center4. Crittenton Hospital and Medical Center5. Forest Health Medical Center6. Gratiot Medical Center7. Harper University Hospital8. Henry Ford Macomb Hospital9. Henry Ford Hospital10. Henry Ford Wyandotte11. Hurley Medical Center12. Lakeland Community Hospital13. Marquette General Hospital14. McLaren Regional Medical Center15. Mercy General Health Partners16. Metro Health in Wyoming17. Munson Medical Center18. Oakwood Hospital19. Port Huron Hospital20. Sparrow Health System21. Spectrum Health System22. St. John Hospital and Medical Center23. St. John Oakland24. St. Mary Mercy Hospital25. St. Mary's Grand Rapids26. University of MI Health System27. Beaumont Troy28. Beaumont Royal Oak29. Huron Valley Sinai30. Henry Ford West Bloomfield31. St. Joseph Mercy Oakland32. North Ottawa Community Hospital

Collaborative quality improvement

• Identifying and implementing best practices– Surgeons learning from their data

– Surgeons learning from each other

Nancy Birkmeyer, PhD Director, MBSC

70 surgeons and program coordinators from 32 programs

Health Affairs, April, 2011

Brainstorm

• What are the best ways to improve surgical quality by focusing on compliance?

Control

Standardizing care across Michigan:

Optimizing VTE prophylaxis for bariatric surgery

Use of Pre-Operative Heparin, 2008

VTE rates by Type of Heparin Used

Birkmeyer NJO et al., Arch Surg, 2013

VTE Risk Calculator and Treatment Guidelines

Rates of VTE Guideline Adherence Over Time

*Based on random site audit of 1,148 charts to verify VTE prophylaxis data

Temporal Trends in Rates of VTE and Death

Challenges with strategies focused on standardization

• It may only get you so far – set’s a low bar• Could potentially stifle innovation – prevent

better solutions from emerging

With standardization there is tension with innovation

Brainstorm

• What are the best ways to improve surgical quality by focusing on relationships?

Collaborate

Modified OSATS Global Rating Scale of Operative Performance

Category Performance rating: 1 (Poor performance) – 5 (Excellent performance)Respect for Tissue 1 2 3 4 5

  Frequently used unnecessary force on

tissue or caused damage by

inappropriate use of instruments

  Careful handling of tissue but occasionally

caused inadvertent damage

  Consistently handled tissues appropriately with minimal damage

Time and Motion 1 2 3 4 5

  Many unnecessary moves

  Efficient time/motion but some unnecessary

moves

  Economy of movement and

maximum efficiencyInstrument Handling 1 2 3 4 5

  Repeatedly makes tentative or awkward

moves with instruments

  Competent use of instruments but

occasionally appeared stiff or awkward

  Fluid moves with instruments and no

awkwardness

Flow of Operation 1 2 3 4 5

  Frequently stopped operating or needed to

discuss next move

  Demonstrated ability for forward planning

with steady progression of operative procedure

  Obviously planned course of operation with effortless flow

from one move to the next

Exposure 1 2 3 4 5

  Poor retraction frequently causing poor

visualization or awkward tissue

alignment

  Good exposure for most of the key steps of

procedure

  Highly skilled retraction. Makes

operation appear easy

Overall Technical Skill 1 2 3 4 5

Chief residentAverage bariatric

surgeonMaster bariatric

surgeon

Note: ◊ represents the mean; bars extend from mean ± standard error.

Average of Six Ratings of Technical Skill

Video # =

N Raters =

Note: ◊ represents the mean; bars extend from mean ± standard error.

Average of Six Ratings of Technical Skill

Video # =

N Raters =

Bottom TopMiddle

p<0.001

p<0.001

p=0.001

Surgeon Skill:

Rafael Nadal

Itzhak Perlman

Next steps

• Cluster randomized trial of a peer-coaching intervention to improve skills and outcomes (AHRQ R01)

• Implement skill rating, best videos, and qualitative feedback on technique for everyone

Challenges to collaborative quality improvement

• It goes against many of our instincts– Can be uncomfortable

• Creating a sense of community takes a significant time commitment

With collaboration there is tension with competition

Collaborate Create

CompeteControl

Adoption of new technology will continue to advance safety but needs to be evidence-based

Center of excellence models will work but only for few rare conditions

Collaborative quality improvement is a powerful tool for large-scale quality improvement but its challenging to engage surgeons

Efforts at compliance with standards and work but generally set a low bar on performance

The secret to using each strategy lies in finding balance with the opposite quadrant

Collaborate Create

CompeteControl

New technology & Innovative surgical approaches

Focus on new ideas

Physicians competing with each other

Focus on the best outcomes

Physicians working together

Focus on building relationships

Policies mandating physician compliance

Focus on compliance with standards

Improving quality = adding value

Our responsibility

External pressures mounting

Physician AlignmentHealth systems acquiring practices, hospitalsPhysician selection – volume, quality, costFinancial incentives/compensation alignedManagement coordination

At-Risk Business ModelsQuality Bonuses and PenaltiesEpisode Payment BundlesCapitation / Population HealthMember Claims Analysis

Physician-led Quality ImprovementOutcomes measurement & analysisPhysician collaboration on best practices & CDSReduced variation in qualityLower, more predictable costs

Act

ivit

y

My clinical trajectory

Bariatric surgery outcomes in Michigan:Mortality = 1/3000 (0.003%)Leak rate = 5/1000 (0.5%)Bleeding = 1/100 (1.0%)Length of stay = 2 days (median)

But we’ve done it before.