Strategies for improving surgical quality: A conceptual framework Justin B. Dimick, MD, MPH Associate Professor of Surgery Department of Surgery University 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 Change Health System Strategic Activity Physician-led Quality Improvement Outcomes measurement & analysis Physician collaboration on best practices & CDS Reduced variation in quality Physician Alignment Health systems acquiring practices, hospitals Physician selection – volume, quality, cost Financial incentives/compensation aligned At-Risk Business Models Quality Bonuses and Penalties Episode Payment Bundles Accountable care organizations

Is this a safety problem? My clinical trajectory

Safety of bariatric surgery in the United States 0.09 0.08 Non-Medicare Medicare 0.07 0.06 0.05 Serious Complication Rate 0.04 0.03 0.02 0.01 0.00 2004 2005 2006 2007 2008 2009 Time (Year) Dimick JB, et al. JAMA 2013

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 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 YELLOW GREEN RED BLUE

Innovative “Out of the box” thinkers Focus on ideas

Warm and cuddly Strong mentoring skills Focus on relationships Innovative “Out of the box” thinkers Focus on ideas

Warm and cuddly Strong mentoring skills Focus on relationships Innovative “Out of the box” thinkers Focus on ideas Driven Competitive “Must win” attitude Focus on results

Warm and cuddly Strong mentoring skills Focus on relationships Innovative “Out of the box” thinkers Focus on ideas Rules and regulations Policy adherence Focus on compliance Driven Competitive “Must win” attitude Focus on results

Brainstorm Compete Create What are the best ways to improve surgical quality by focusing on competition?

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 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

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

Michigan Bariatric Surgery Collaborative Beaumont Grosse Pointe Borgess Medical Center Bronson Medical Center Crittenton Hospital and Medical Center Forest Health Medical Center Gratiot Medical Center Harper University Hospital Henry Ford Macomb Hospital Henry Ford Hospital Henry Ford Wyandotte Hurley Medical Center Lakeland Community Hospital Marquette General Hospital McLaren Regional Medical Center Mercy General Health Partners Metro Health in Wyoming Munson Medical Center Oakwood Hospital Port Huron Hospital Sparrow Health System Spectrum Health System St. John Hospital and Medical Center St. John Oakland St. Mary Mercy Hospital St. Mary's Grand Rapids University of MI Health System Beaumont Troy Beaumont Royal Oak Huron Valley Sinai Henry Ford West Bloomfield St. Joseph Mercy Oakland 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 Control What are the best ways to improve surgical quality by focusing on compliance?

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 Collaborate 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 Many unnecessary moves Efficient time/motion but some unnecessary moves Economy of movement and maximum efficiency Instrument Handling 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 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 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 Chief resident Average bariatric surgeon Master bariatric surgeon

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 Bottom Middle Top Video # = N Raters = Note: ◊ represents the mean; bars extend from mean ± standard error.

p<0.001 p<0.001 Surgeon Skill: p=0.001

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

Collaborative quality improvement is a powerful tool for large-scale quality improvement but its challenging to engage surgeons Adoption of new technology will continue to advance safety but needs to be evidence-based Efforts at compliance with standards and work but generally set a low bar on performance Center of excellence models will work but only for few rare conditions

The secret to using each strategy lies in finding balance with the opposite quadrant Collaborate Create Compete Control New technology & Innovative surgical approaches Focus on new ideas Physicians competing with each other the best outcomes working together Focus on building relationships Policies mandating physician compliance with standards Improving quality = adding value

Our responsibility

External pressures mounting Activity Physician-led Quality Improvement Outcomes measurement & analysis Physician collaboration on best practices & CDS Reduced variation in quality Lower, more predictable costs Physician Alignment Health systems acquiring practices, hospitals Physician selection – volume, quality, cost Financial incentives/compensation aligned Management coordination At-Risk Business Models Quality Bonuses and Penalties Episode Payment Bundles Capitation / Population Health Member Claims Analysis

But we’ve done it before.