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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
13
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!
14
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
15
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
16
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!
17
Project Dashboard
Project Dashboard
19
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)
23
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.
24
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
3030
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
3333
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
3434
"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”
3636
3737
Challenges
3838
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
4040
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
4343
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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