How to Build an Effective Surgical Quality Program

J.H. “Pat” Patton, Jr., MD, FACSJennifer Ritz, RN, BSN

Henry Ford Hospital

903-bed tertiary care hospital, education and research complex located in Detroit's New Center area.

Multi-organ transplantation center Level 1 trauma center Accredited Chest Pain Center National Stroke Center >1,000 physician group practice 22,000 operations annually

Joined ACS NSQIP in June of 2006– No previous mechanism to measure surgical

outcomes

Collected data on General and Vascular Surgery

First ACS NSQIP Semi-Annual Report received in January 2007

Expanded to multispecialty NSQIP in 2008

Henry Ford Hospital

HFH

2006 NSQIP Data

2006 NSQIP Data

HFH

The 5 Phases of NSQIP Grief1. Denial: My patients are sicker, my operations

harder…

2. Anger: (do we really need to give you an example?)

3. Bargaining: Ok, let me look at that data, I can make some sense of it, its clearly flawed and only I can explain it to you.

4. Sadness: Are we killing them? Do we really Suck?

5. Acceptance: What should we do now? Help

What we did

Deep dives into the data – Utilized unadjusted reports– Identified “low hanging fruit”

Share the data– Explain what it means, where it comes from, why its

important Identify interested stakeholders/champions

– “surgical ownership”– “quality ownership”– “nursing ownership”– “anesthesia ownership”

“low hanging fruit”

VTE incidence, inconsistent prophylaxis

Comparison of HFH to NSQIP database: 5/29/06 – 12/1/06

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

HFH NSQIP

DVT

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

HFH NSQIP

PE

PercentPercent

Comparison of HFH to NSQIP database: 01/01/07 – 01/31/08

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

HFH NSQIP

DVT

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

HFH NSQIP

PE

PercentPercent

2007 NSQP DATA

HFH

2007-2008 NSQIP Data

HFH

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Improvement and Data

Organizing your data mess: – Nobody believes me, how do I make sense of

it? where do I get it? How do I display it? Methods for Improvement:

– I have the data, now what the *^%^&*R&^ do I do with it?

Educate, Educate, Educate: – if you don’t know what an O/E ratio is, you can’t

celebrate improving it!

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Methods to Get Started

Fix the Issues – Start small one project at a time-pilot a project

“low hanging fruit”– Copy best practice-don’t waste time reinventing

the wheel– Find out what works-utilize resources

Give The Team Faith– Emphasize success – Communicate results

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Systematic Review of Information Outside agency required measures Dashboard (regularly updated measures

related to key projects and day to day operation)

Deep dives into topics. Where results are not what are desired take the time to understand process and drivers of the outcomes.

Listen to Gripes

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First Rule of Data to Monitor Processes

Track data over time! If it is not a run chart then ask to see it

as a run chart!

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Project Dashboard

Project Dashboard

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Portion of DashboardHFH Neurosurgery

Mortality Rate NSQIP

0%

1%

2%

3%

4%

5%

6%

3Q08

4Q08

1Q09

2Q09

3Q09

4Q09

1Q20

10

HFH HFH Average National Average

HFH Neurosurgery All Occurrence Rate NSQIP

0%

5%

10%

15%

20%

25%

3Q08

4Q08

1Q09

2Q09

3Q09

4Q09

1Q20

10

HFH National Average

HFH Neurosurgery Occurrence by Type

2.2%

5.5%

1.1% 1.1%

0.0%

3.3%

0.0%

1.8%

4.0%

0.4%

1.3%

0.1%

3.1%

4.3%

0%

1%

2%

3%

4%

5%

6%

WoundOccurrences

RespiratoryOccurrences

Urinary TractOccurrences

CentralNervousSystem

Occurrences

CardiacOccurrences

Other SurgicalOccurrences

OtherOccurrences*

HFH AC 500+

Project Dashboard

Project Dashboard

Fix based on Raw Data, but follow the adjusted long-term

Implementation of the National Surgical Quality Improvement Program: Critical Steps to Success for Surgeons and HospitalsVic Velanovich, MD, FACS, Ilan Rubinfeld, MD, FACS,Joe H. Patton jr, MD, FACS, Jennifer Ritz, RN, Jack Jordan, Scott Dulchavsky, MD, PhD, FACS

(Am J Med Qual 2009;24:474-479)

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Educate about Shared Destiny:

Its OUR data Present your unadjusted and semi-annual

reports publically Devote some of the existing conference time to

reviewing it, it must be how you run the business!

Allow time for questions Seek interested collaborators Show them the curve they do well on. Show them the curve they fall short on.

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Educate about Shared Destiny

Few, if any, health care professionals understand the shared destiny of our outcomes

We live in Nursing, Anesthesia, Emergency, Surgery silos. Our Quality Group is still mostly a Silo!!!

Educating about this data is necessary to help foster the collaborative work you must develop to improve.

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Why are we here?

I want my patients to get better care – safer, better outcomes, more efficient.

I’m going to work to make that happen!

Physicians Inherently Care Deeply About Quality But….. Time per visit is decreasing Proliferation of guidelines is confusing Data shared with physicians is often

inadequate or statistically flawed Incomes (for many) have decreased Trust between physicians and

reviewers/payors is poor (and without an EMR – they have the data)

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Who Should Lead Surgical QI:The Surgeon Champion

"The question. 'Who ought to be boss?', is like asking, 'Who ought to be the tenor in the

quartet?' Obviously, the man who can sing tenor." - Henry Ford

Surgeons: Born Leaders…..or not?

Innate or Nurtured? High need for

autonomy Sensitivity to criticism Perfectionistic &

compulsive Want to direct; resist

control Often low self esteem

2828From Barry Silbaugh, MD, ACPE

The Safe Path

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The Unsafe Path

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ACTIVE AND PASSIVELEADERSHIP

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GOODGOOD

BADBAD

PASSIVEPASSIVE ACTIVEACTIVEEmpowers othersEmpowers othersWon’t micromanageWon’t micromanageMethodical progressMethodical progress

IndecisiveIndecisiveRisk averseRisk averseSeems confusedSeems confused

Commands/ActsCommands/ActsCharts the courseCharts the courseThinks ~fast~forwardThinks ~fast~forward

Ego drivenEgo drivenAlienates subordinatesAlienates subordinatesHigh EmotionsHigh Emotions

ACTIVE AND PASSIVELEADERSHIP

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GOODGOOD

BADBAD

PASSIVEPASSIVE ACTIVEACTIVEEmpowers othersEmpowers othersWon’t micromanageWon’t micromanageMethodical progressMethodical progress

IndecisiveIndecisiveRisk averseRisk averseSeems confusedSeems confused

Commands/ActsCommands/ActsCharts the courseCharts the courseThinks ~fast~forwardThinks ~fast~forward

Ego drivenEgo drivenAlienates subordinatesAlienates subordinatesHigh EmotionsHigh Emotions

• Champion vs. AuthorityChampion vs. Authority• Influence vs. ControlInfluence vs. Control• Persuasion vs. CoercionPersuasion vs. Coercion

What’s not working?

“Time stealing” activities at the hospital – long, non-productive committee meetings; frustrating, inefficient work processes

Regarding physicians as “customers” Seeing physicians as “production workers” instead

of “knowledge workers” Failure to view physicians as “partners” in

improving patient care Overemphasis on patient’s satisfaction with

“amenities” – not strong focus on safety/quality

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What works?

Getting physicians involved from the start of a project

Finding a precious few clinical leaders who are interested in system improvement

Running a meeting that’s meaningful to physicians – agenda, starts on time, short, action-oriented, follow-up, shows progress

Viewing physicians as partners in quality agenda; “The patient is the only customer”

Understanding the nuances of influence in different specialties – physicians are best at this!!

Sharing data – even raw data – with physicians

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"Never tell people how to do things. Tell them what to do

(and why) and they will surprise you with their

results."

Gen. George S. Patton

How Surgeons Want To See Their Leaders

Advocate Protector Communicator First among equals,

“not one millimeter above”

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Challenges

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Traditional Leaders vs. Meta-Leaders:

– Traditional leaders derive their power and influence from within their organizational silos (i.e., job description, authority of position, expectations of supervisor and subordinates)

1. Promotes a related set of functions2. Controls a related set of workers3. Is the sum of all the parts - Newtonian Systems4. Supports a structured/familiar Organization5. Operates under a defined set of principles 6. Is tied together by a unique culture

LE

AD

ING

IN

TH

E S

ILO

L

EA

DIN

G I

N T

HE

SIL

O

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Meta-LeadershipD

epar

tmen

t C

hai

rs

Dep

artm

ent

Ch

airs

Surgical ServicesSurgical Services

• Big pictureBig picture• Multi-dimensional perspectiveMulti-dimensional perspective• Comfortable with the unfamiliarComfortable with the unfamiliar• Recognize cultural valueRecognize cultural value• Can integrate diverse goals Can integrate diverse goals

COMPLEX ADAPTIVE SYSTEMSCOMPLEX ADAPTIVE SYSTEMSMore than the sum of the More than the sum of the

individual partsindividual parts

Key Characteristics of a Meta-Leader

Understands their Emotional Intelligence (EI) Courage to take risks and manage consequences Sensible in understanding and managing various

organizational cultures – works inside and outside the silo

Curious – asks good questions Connects all the pieces Conflict Solver – recognize, manage, and solve Focuses on the complex problem and larger

solution

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Tools for Your Toolbox

Be A Meta-Leader – Lead Connectivity: Connect the purposes of different departments to achieve

a greater good– Use structure (checklists,procedures) to gain control– Champion issues– Influence followers– Persuade action

Take risks and manage consequences Be Curious – ask good questions always Recognize, manage, and resolve conflict Focus on the complex problem and larger solution

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Improvement = Behaviors = “Culture”

The way we do things around here.Behavior (culture) change starts with us………..What do we do when no one’s watching?Who’s accountable? You? Someone else? Everyone?

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Iron Laws of Improvement

B Teams with A Systems always beat A Teams with B Systems– It’s the systems stupid…– We need an A team, not A individuals and we need to provide that

team with A systems

It’s not the seed, it’s the soil– Culture trumps all– Innovation must be balanced with Spread– The political is much more challenging than the technical

Data + Anecdote = Action– You need both

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Recommendations for Physicians

Be curious first……critical second

Remember its “Our Team” not “My Team”

Learn new knowledge competencies – PI, influence, science of reliability

Take time to listen (to your SCR) – and hear what’s really being said

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