Improving Surgical Quality: Tracking Emergent vs. Elective Surgery

This article in Health Leaders provides an important reminder about the need for performance improvement experts to understand our data in more detail. Many hospitals formally evaluate various surgical quality measures, including the Surgical Care Improvement Project (Core Measures), complications, infections, readmissions, mortality, returns to the OR, returns to the ICU. However, these hospitals may not be differentiating between Emergency Surgery vs. Elective Surgery, a variable that can change the likelihood of complications considerably.

This research being undertaken at Wake Forest University Medical Center underscores that unless we understand the variables behind the data that we are collecting, we will likely not understand how to truly improve outcomes.

Another danger in "aggregating data" - particularly in this day of mandated physician profiling, e.g., through the Ongoing Professional Practice Evaluation (OPPE) - is that we may project individual practitioners to have higher complication rates than their peers, when in reality they may have a selective patient population. For example, perhaps some practitioners take more emergency call than their peers, which would lead them to perform more emergent procedures. 

Other variables, such as delay in performing surgery, quality of OR team, communication within the OR/ preoperative timeframe, may also play a role in the outcome of the procedure. However, unless we are attuned to these variables, capturing them, and studying them, we will not be serving the cause of improvement nor will we be able to effectively engage and help our physician colleagues as actively as we would like.

Dangerous Assumptions & Lack of Systems: Breakdown in Communication of Test Results

This article in the Washington Post points out a disturbing, yet unfortunately widespread, cause of medical errors: breakdown in communication of test results.

The Joint Commission addresses the issue as one of its National Patient Safety Goals for hospitals. However, systems at many hospitals and physician offices are not "airtight" enough to assure the reliable transmission of information and the delivery of safe care.

The "root cause" for this error generally comes down to one of a few common factors:

• Staff too busy with their "day-to-day" routine. 
• If the result reporting process is not well-integrated into their clinical workflow, there is a high likelihood of system failure.
• No clear process identified for handling of critical lab results.
• This is probably the "over-arching" root cause for the issue at hand. If the process for communication is not robust, not well disseminated, and not monitored, it will inevitably lead to errors. 
• Miscommunication about who in the hospital/ office is handling the communication.
• Results may get reported to a non-clinical staff member (such as a Unit Clerk or Office Manager) who is not the right individual to interpret the significance of the findings.
• Physician was not reachable despite numerous attempts.
• Sorry to say that this is probably one of the most common reasons for failure to relay critical test information, particularly in a busy hospital setting. 
• Lab techs, nurses, and other staff try to follow an "established process", but the process is doomed to repetitive failure because one of the key steps is not reliable.
• Results get communicated, but subsequent "changes to reports" are lost. 
• Unfortunately, this happens often for tests that have to be "incubated" (such as microbiology reports) or "reviewed" (such as radiology reports).
• Test results that cross clinical settings (such as hospital to provider office) are prone to getting lost. 
• Every provider and every hospital may have a different mechanism and process for communicating critical test results. This increases the complexity of the process exponentially, and makes it more prone to break down.
• When there is not "one standardized process for communication" across the local healthcare system, how do we expect individual physicians, staff, and even organizations to ensure reliability?

The system described by Dr. Eric Poon at Brigham and Womens Hospital is a constructive approach to this problem:

However, this system is mostly reliant on an electronic interface, which may not be applicable to all providers in a diversity of clinical settings. In addition to using electronic systems wisely, healthcare providers should remember the key principles of performance improvement for systematically reducing the likelihood of error in this vital clinical process:

• Undertake a root cause analysis for any specific errors at the respective institution
• Undertake a FMEA (failure modes effect analysis) to formally assess the likelihood of systems breakdown for key processes
• Ensure that a specific process is laid out and communicated widely to all staff and physicians
• Build in redundancies to ensure that an "adequate safety net" is in place to catch errors before they affect a patient
• Monitor data both on outcomes (errors reaching the patient) as well as critical steps in the process (such as success in test result handoffs)
• Report data widely to staff, physicians, leadership
• Provide feedback to staff and physicians on individual errors
• Incorporate education about process into staff orientation and ongoing training forums

How to Address Cleanliness Violations at Hospital? New Building or Performance Improvement

The LA Times posted this article about UCLA Harbor Medical Center's safety violations stemming from "lack of cleanliness".

The plan for correction: "Los Angeles County is spending nearly $323 million to construct a 190,000-square-foot building at the hospital that will replace both the surgical facilities and the emergency room. "

As some of the comments to the story point out, its not all about the facility - its also about management and leadership. I've worked with organizations that have faced even older infrastructure, and yet we have improved their cleanliness with good old fashioned management and systems:

• Leadership recognized the difficult situation but resolved to address it.
• Management threw its shoulder "to the flywheel" and made it turn.
• A voluntary team of "cleanliness inspectors" toured the hospital on a regular basis and documented cleanliness of high risk areas - in a manner that could be measured, easily disseminated, and compared.
• Performance improvement systems were installed to ensure improvement:
• Pulled together a "performance improvement team" to oversee the issue.
• Measured the results.
• Made the measurement consistent and reliable.
• Disseminated the findings.
• Developed policies for cleanliness that could be adhered to by all.
• Ensured accountability by reporting on the team's findings to the governing body through the appropriate oversight committees.
• Made the "clicks of the fly wheel visible to all" by showing that some departments (that were just as resource-starved as the others) were able to make improvements.

Perhaps a new building is necessary at UCLA Harbor for many reasons, but in order to reform healthcare, we as a society have to start recognizing that adding costs (staffing, equipment, and buildings) to solve a problem are not sustainable interventions. Improving leadership, management, and systems are.


ADDENDUM 11/1/11: This story published subsequently in the Daily Breeze provides further details about a corrective action plan being put into place at UCLA Harbor. "Those fixes include a reorganization and restructuring of the hospital's infection prevention and control unit, identifying problems with the physical plant and enhancing efforts to assure staff members are washing their hands and practicing good hygiene." All of these actions appear to be appropriate, however, the key to real and sustained improvement from the "corrective action plan" is to ensure that the actions are monitored regularly, and that comprehensive performance improvement systems are implemented.

C-Section Rate Variability at MA Hospitals: A Tale of Culture & Performance Improvement Systems

This story in the Boston Globe Magazine is ostensibly about c-sections:

However, the underlying factors leading to high rates at some MA hospitals are all related to culture and/or implementation of performance improvement systems:

(1) Hospital Culture

(2) Physician Culture

(3) Monitoring of Outcomes

(4) Sharing of Outcomes

(5) Use of Report Cards

(6) Design of Systems to Facilitate Outcomes

Performance Improvement Tip of the Day: The TrendWatch

The Trendwatch is a finely crafted performance improvement tool that provides a lot of "punch" in just one page.

(1) Updated Performance - helps to communicate the latest data to your team, physicians, and staff members.

(2) Barriers or Gaps to Performance - helps your team to keep their eyes on the "root causes" of poor performance.

(3) Initiatives Implemented - helps you keep track of what interventions you have tried to improve performance, along with dates of implementation.

(4) Other Prioritized Initiatives - helps you keep track of interventions that you intend to try, lest you forget some great ideas that someone brought up earlier in the process!

Those who have used the tool report that it has been a great aid to their initiatives - it keeps information organized, provides focus, and helps to keep everyone on the same "page".

This TrendWatch tool was provided courtesy of 

Physician Performance Improvement Institute (PPII).