Quality Assurance for Quality Assurance for Cardiac SurgeryCardiac Surgery

Vincent A. Gaudiani, MDVincent A. Gaudiani, MDLuis J. Castro, MDLuis J. Castro, MDAudrey L. Fisher, MPH Audrey L. Fisher, MPH

Pacific Coast Cardiac & Vascular SurgeonsPacific Coast Cardiac & Vascular SurgeonsRedwood City, CARedwood City, CA

California Society of Thoracic Surgeons Annual MeetingStanford University, July 30th, 2005

Quality Assurance is the largest Quality Assurance is the largest structural problem facing structural problem facing cardiac surgerycardiac surgeryRecertificationRecertificationPatient SafetyPatient SafetyTrainingTrainingPublic ResponsibilityPublic Responsibility

Maintenance of Certification: A Maintenance of Certification: A Message from Message from the American Board of Thoracic the American Board of Thoracic Surgery (ABTS)* Surgery (ABTS)* William A. Gay, Jr, MD* William A. Gay, Jr, MD*

What Is MOC? What Is MOC?   "A comprehensive process...based on quality "A comprehensive process...based on quality standards set by member boards and other standards set by member boards and other standard-setting organizations...focusing on standard-setting organizations...focusing on the the continuouscontinuous process of assessment and process of assessment and improvement of a physician over the course of improvement of a physician over the course of his/her career." his/her career."

Maintenance of Certification: A Maintenance of Certification: A Message from Message from the American Board of Thoracic the American Board of Thoracic Surgery (ABTS)* Surgery (ABTS)* William A. Gay, Jr, MD* William A. Gay, Jr, MD*

What Are the Options for the ABTS? What Are the Options for the ABTS?   Dr Gordon Olinger, immediate past Examination Dr Gordon Olinger, immediate past Examination Chair of the ABTS, answered this question as Chair of the ABTS, answered this question as follows: follows: 1. "Accept the status quo, assuming that the 1. "Accept the status quo, assuming that the

present program adequately addresses the issue. present program adequately addresses the issue. 2. 2. Audit practice performance, pitting one Audit practice performance, pitting one

physician’s performance against another’s. physician’s performance against another’s. 3. Change to a program documenting 3. Change to a program documenting

participation in a valid process of assessment and participation in a valid process of assessment and improvement in quality of care as measured improvement in quality of care as measured against evidence-based standards."against evidence-based standards."

DefinitionsDefinitions

Adult cardiac surgery is an ethical Adult cardiac surgery is an ethical business that provides potentially business that provides potentially dangerous services to under dangerous services to under informed, frightened customersinformed, frightened customers

Cardiac surgeons succeed best when Cardiac surgeons succeed best when they provide optimal information, they provide optimal information, operations, aftercare, and comfort in operations, aftercare, and comfort in a safe environmenta safe environment

DefinitionsDefinitions

QA is QA is not simplynot simply a mechanism for a mechanism for reviewing results after cardiac reviewing results after cardiac operations – the m&m modeloperations – the m&m model

QA is an enabling atmosphere, an QA is an enabling atmosphere, an attitude, that surrounds all attitude, that surrounds all professional interactions with the professional interactions with the patient and is refined and reinforced patient and is refined and reinforced at regular meetingsat regular meetings

Who is in charge of QA?Who is in charge of QA?

NOT just physicians and nurses, but NOT just physicians and nurses, but every person who serves or touches every person who serves or touches the patientthe patient

Every team member must be Every team member must be encouraged to report problems and encouraged to report problems and suggest solutionssuggest solutions

The QA TeamThe QA Team

Core group includes includes Core group includes includes

all relevant nursing leadership, all relevant nursing leadership, perfusion, anesthesia, physician perfusion, anesthesia, physician assistants, surgeonsassistants, surgeons

Invite anyone else whose work Invite anyone else whose work touches on a problem areatouches on a problem area

The principle is that The principle is that all all stakeholders must be present at stakeholders must be present at one time to solve QA problemsone time to solve QA problems

The QA GoalThe QA Goal

The goal is The goal is not not to assign blame for to assign blame for failurefailure

The goal is to improve performanceThe goal is to improve performance

QA QuestionsQA Questions

What is happening?What is happening? How does it relate to other aspects How does it relate to other aspects

of patient care?of patient care? Is it optimal?Is it optimal? How can it be improved?How can it be improved? Minutes and follow upMinutes and follow up

The QA VenueThe QA Venue

Quarterly meetings to review Quarterly meetings to review results, trend, compare to national results, trend, compare to national databasesdatabases

Identify and solve process problemsIdentify and solve process problems Assess customer satisfactionAssess customer satisfaction

Critical QA JobsCritical QA Jobs

Assess, Improve, & Manage:Assess, Improve, & Manage: Patient SatisfactionPatient Satisfaction Process (Institutional, Clinical, etc.)Process (Institutional, Clinical, etc.) OutcomesOutcomes Appropriateness of CareAppropriateness of Care Efficiency of Resource ManagementEfficiency of Resource Management

These interlockThese interlock

Patient Satisfaction 1Patient Satisfaction 1

The patient has a dual role as the The patient has a dual role as the object of QA and an important object of QA and an important contributor to the QA environmentcontributor to the QA environment

Patient Satisfaction 2Patient Satisfaction 2

Call patients 30 days after Call patients 30 days after discharge. Most are grateful to be discharge. Most are grateful to be alive, so specifically ask what could alive, so specifically ask what could have been improvedhave been improved

Assume that those rare, spontaneous Assume that those rare, spontaneous complaints are complaints are commoncommon problems problems

Walk through the patient’s Walk through the patient’s experienceexperience

ProcessProcess

Process refers to the interaction of Process refers to the interaction of hospital services with personnel and hospital services with personnel and patientspatients

The institution serves by providing a The institution serves by providing a safe, efficient, and pleasant safe, efficient, and pleasant environmentenvironment

QA is the best mechanism for QA is the best mechanism for caregivers and hospital service caregivers and hospital service providers to solve “process” problemsproviders to solve “process” problems

Meeting Agenda: Meeting Agenda: Process IssuesProcess Issues

Topic Presenter

Operating Room Time Efficiency Surgeons/Fisher

Financial Report Administration

Preventing Medication Errors Castro/Pharmacy/ICU

Chloraprep Change – New Colored Version Infection Control

Defibrillators bedside Castro / Gaudiani/ ICU

Digital X-Ray System Radiology

Procainamide Monitoring Laboratory

Adequate Blood for Low BSA Patients Laboratory / Perfusion

Override of Pyxis ICU / Pharmacy

No Narcotics for Patients 80+ y.o. ICU / Pharmacy

All Valve Patients: Discharge on Dyazide Pharmacy/ Physician’s Assts.

Assessing ResultsAssessing Results

Clinical outcomes must improve Clinical outcomes must improve and/or meet national standardsand/or meet national standards

Surgeons must lead the QA processSurgeons must lead the QA process

QA Ground Rules 1QA Ground Rules 1

The patient isThe patient is never never the cause of the cause of failurefailure

The surgeon can be the cause of The surgeon can be the cause of failurefailure

QA Ground Rules 2QA Ground Rules 2

Most failures are the result of Most failures are the result of personnel problems interacting with personnel problems interacting with process problemsprocess problems

Personnel problems must be Personnel problems must be resolved by educationresolved by education

Process problems must be resolved Process problems must be resolved by ruthless diagnosis and by ruthless diagnosis and interventionintervention

QA OrganizationQA Organization

QA manager with data skills and QA manager with data skills and access to surgeons. The access to surgeons. The “headlights”“headlights”

24 hour voicemail to record quality 24 hour voicemail to record quality issuesissues

Regular meetings that delay the Regular meetings that delay the surgery schedule so everyone comessurgery schedule so everyone comes

QA ActionsQA Actions

Review quarterly results for Review quarterly results for mortality and morbidity mortality and morbidity with with trending trending

Compare institutional results to Compare institutional results to national (STS) resultsnational (STS) results

Frankly review bad outcomesFrankly review bad outcomes Discuss and Discuss and resolveresolve QA problems in QA problems in

all categoriesall categories

Outcomes:Outcomes:Quarterly Quarterly SummarySummary

2005 Case-Mix:2005 Case-Mix:Sequoia vs. NationalSequoia vs. National

74%

27%

11%

29%

3%7%

4%

13%8%

24%

0%

10%

20%

30%

40%

50%

60%

70%

80%

CAB AVR MVR MVV Other

Nat'lSEQ

2.9%

3.8%

2.9%2.5% 2.4%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

2000 2001 2002 2003 2004

SEQUOIA

STS 2003 (3.4%)

+2 SD 4.0%

-2 SD 1.8%

Sequoia Hospital Cardiac Surgery

Operative Mortality (No Risk Adjustment)

2000- 2004

3.4 STS Overall Mean

+2 SD (4.0%)

-2 SD (1.8%)

Cardiac Surgery: 4th Quarter 2004 Cardiac Surgery: 4th Quarter 2004 Mortality Report Mortality Report

NameName StatuStatuss

ProcProc Preop HxPreop Hx CompsComps DeathDeath

DoeDoe

1/61/622ndnd Op Op

UrgenUrgentt

82M82M

TVR,TVR,

Exc 3 Exc 3 pacing pacing wires,wires,

Implant Implant Bivent Bivent EpicardEpicard

Pacing Pacing system,system,

leads & leads & generatgeneratoror

Severe TR, NYHA 3, Severe TR, NYHA 3, CAD, severe Pulm CAD, severe Pulm HTN, Mean PA 47HTN, Mean PA 47

PMH: PPM x4-latest PMH: PPM x4-latest 2002, PCI-2002, 2002, PCI-2002, AVR, MVR-1973, AVR, MVR-1973, remote CVAremote CVA

EF 65%EF 65%

MRSA pneumonia, MRSA pneumonia, RF w/Pk Cr 3.7, DC RF w/Pk Cr 3.7, DC Cr 1.7Cr 1.7

Trans to Fresno Trans to Fresno Community Hospital Community Hospital POD 20POD 20

Expired on POD 34 Expired on POD 34 in Fresno Hospital in Fresno Hospital (Per 30D follow-up)(Per 30D follow-up)

Expired Expired OOHOOH

POD 34POD 34

DoeDoe

1/71/711stst Op Op

UrgenUrgentt

73M73M

MVV, MVV, TVR, TVR, MazeMaze

Severe MR/TR, Severe MR/TR, NYHA 3, NYHA 3, Biventricular Failure Biventricular Failure w QRS=170 ms and w QRS=170 ms and greatly enlarged greatly enlarged chambers especially chambers especially on right, Hepatic on right, Hepatic Dysfunction NIDDM, Dysfunction NIDDM, HTN, Chronic AfibHTN, Chronic Afib

Renal Failure req Renal Failure req CVVH, Liver Failure, CVVH, Liver Failure, On/off Ventilator, On/off Ventilator, Aspiration Aspiration Pneumonia, Sepsis, Pneumonia, Sepsis, Sternal dehiscence Sternal dehiscence req rewire, CHB - req rewire, CHB - BiV Pacer placedBiV Pacer placed

Multisystem failureMultisystem failure

ExpiredExpired

PODPOD

4242

2.7%

1.8%

1.1%

0.8%

1.2%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

2000 2001 2002 2003 2004

SEQUOIA

STS 2003

+2 SD 2.8%

-2 SD 0%

Sequoia Hospital Cardiac Surgery

Permanent Stroke (No Risk Adjustment)

2000 – 2004

1.6% STS Overall Mean

+2 SD (2.8%)

-2 SD (0%)

Stroke Improvement Stroke Improvement ProcessProcess

TEE on all casesTEE on all cases Selective cerebral perfusionSelective cerebral perfusion Head down coming off bypassHead down coming off bypass Better air maneuversBetter air maneuvers New intraoperative management of New intraoperative management of

severely calcified and grade IV severely calcified and grade IV aortasaortas

External Review of External Review of Appropriateness Cardiac Appropriateness Cardiac

SurgerySurgery

Rationale for External Rationale for External ReviewReview

Tenet’s Redding Medical CenterTenet’s Redding Medical Center Blue Cross questioning at least 3 other Tenet Blue Cross questioning at least 3 other Tenet

facilitiesfacilities Senate Finance Committee request for Blue Cross Senate Finance Committee request for Blue Cross

data on Tenet hospitalsdata on Tenet hospitals Health plans seek assurance of appropriateness of Health plans seek assurance of appropriateness of

care for their memberscare for their members Employers (PBGH and CalPERS) seek assurance of Employers (PBGH and CalPERS) seek assurance of

appropriateness of care for their insuredsappropriateness of care for their insureds Current challenges to achieve effective quality Current challenges to achieve effective quality

assurance/peer review in U.S. hospitals assurance/peer review in U.S. hospitals

Desired Desired OutcomeOutcome

Assurance of appropriateness of cardiac Assurance of appropriateness of cardiac procedures for:procedures for: Cardiac patients and their familiesCardiac patients and their families Community at largeCommunity at large Referring physicians/hospitalsReferring physicians/hospitals EmployersEmployers Health plansHealth plans Regulatory agenciesRegulatory agencies

Appreciation on the part of the medical Appreciation on the part of the medical staff for assistance in peer review processstaff for assistance in peer review process

ACC/AHA GuidelinesACC/AHA Guidelines Class IClass I – conditions for which there is evidence and/or – conditions for which there is evidence and/or

general agreement that a given procedure or treatment is general agreement that a given procedure or treatment is useful and effectiveuseful and effective

Class IIClass II – Conditions for which there is conflicting – Conditions for which there is conflicting evidence and/or a divergence of opinion about the evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatmentusefulness/efficacy of a procedure or treatment Class IIa - Weight of the evidence/opinion is in favor of usefulness/efficacyClass IIa - Weight of the evidence/opinion is in favor of usefulness/efficacy Class IIb - Usefulness/efficacy is less well established by evidence/opinionClass IIb - Usefulness/efficacy is less well established by evidence/opinion

Class IIIClass III – Conditions for which there is evidence and/or – Conditions for which there is evidence and/or general agreement that the procedure/treatment is not general agreement that the procedure/treatment is not useful/effective and in some cases may be harmfuluseful/effective and in some cases may be harmful

Resource Resource ManagementManagement

Operating Room Time: Operating Room Time:

A Measure of Quality A Measure of Quality and Resource and Resource ManagementManagement

Average Total Operating Room Average Total Operating Room

Times for Major CategoriesTimes for Major Categories

3:07

3:21

3:36

3:50

4:04

4:19

4:33

4:48

5:02

1998 1999 2000 2001 2002 2003 2004

OR

Tim

e (

H:M

M) CAB+AVR

CAB

AVR

MVV

Primary Coronary BypassPrimary Coronary Bypass(n=995)(n=995)

2:52

3:21

3:50

4:19

4:48

5:16

5:45

1998 1999 2000 2001 2002 2003 2004

OR

Tim

e (

H:M

M)

+/-

SD

Mitral Valve RepairMitral Valve Repair(n=332)(n=332)

2:52

3:21

3:50

4:19

4:48

5:16

5:45

1998 1999 2000 2001 2002 2003 2004

OR

Tim

e (

H:M

M)

+/-

SD

Aortic Valve ReplacementAortic Valve Replacement(n=535)(n=535)

2:52

3:21

3:50

4:19

4:48

5:16

5:45

1998 1999 2000 2001 2002 2003 2004

OR

Tim

e (H

:MM

)+

/- S

D

Aortic Valve Replacement + Aortic Valve Replacement + Coronary Bypass Coronary Bypass

(n = 271)(n = 271)

2:24

2:52

3:21

3:50

4:19

4:48

5:16

5:45

1998 1999 2000 2001 2002 2003 2004

OR

Tim

e (

H:M

M)

+/-

SD

QA Fails When:QA Fails When:

Surgeons fail to recognize and Surgeons fail to recognize and discuss their own failuresdiscuss their own failures

Competing groups use QA to Competing groups use QA to competecompete

QA organization is hierarchalQA organization is hierarchal

ConclusionConclusion

Each man’s death diminishes thee…so ask Each man’s death diminishes thee…so ask not for whom the bell tolls…it tolls for theenot for whom the bell tolls…it tolls for thee