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Quality Assurance for Cardiac Surgery Vincent A. Gaudiani, MD Luis J. Castro, MD Audrey L. Fisher, MPH Pacific Coast Cardiac & Vascular Surgeons Redwood.

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Presentation on theme: "Quality Assurance for Cardiac Surgery Vincent A. Gaudiani, MD Luis J. Castro, MD Audrey L. Fisher, MPH Pacific Coast Cardiac & Vascular Surgeons Redwood."— Presentation transcript:

1 Quality Assurance for Cardiac Surgery Vincent A. Gaudiani, MD Luis J. Castro, MD Audrey L. Fisher, MPH Pacific Coast Cardiac & Vascular Surgeons Redwood City, CA California Society of Thoracic Surgeons Annual Meeting Stanford University, July 30 th, 2005

2 Quality Assurance is the largest structural problem facing cardiac surgery Recertification Recertification Patient Safety Patient Safety Training Training Public Responsibility Public Responsibility

3 Maintenance of Certification: A Message from the American Board of Thoracic Surgery (ABTS)* William A. Gay, Jr, MD* What Is MOC? "A comprehensive process...based on quality standards set by member boards and other standard-setting organizations...focusing on the continuous process of assessment and improvement of a physician over the course of his/her career." What Is MOC? "A comprehensive process...based on quality standards set by member boards and other standard-setting organizations...focusing on the continuous process of assessment and improvement of a physician over the course of his/her career." What Is MOC? Top Introduction What Is MOC? What Are the Options... Footnotesp troduction at Are the Options... otnotes "A comprehensive process...based on quality standards set by member boards and other standard-setting organizations...focusing on the continuous process of assessment and improvement of a physician over the course of his/her career." (ABMS Press Release, March 2003). What Are the Options for the ABTS? What Are the Options for the ABTS? Top Introduction What Is MOC? What Are the Options... Footnotesp troduction at Is MOC? otnotes Dr Gordon Olinger, immediate past Examination Chair of the ABTS, answered this question as follows: 1 "Accept the status quo, assuming that the present program adequately addresses the issue. 2 Audit practice performance, pitting one physician’s performance against another’s. 3 Change to a program documenting participation in a valid process of assessment and improvement in quality of care as measured against evidence-based standards." (G. N. Olinger, ABMS White Paper.)

4 Maintenance of Certification: A Message from the American Board of Thoracic Surgery (ABTS)* William A. Gay, Jr, MD* What Is MOC? Top Introduction What Is MOC? What Are the Options... Footnotesp troduction at Are the Options... otnotes "A comprehensive process...based on quality standards set by member boards and other standard-setting organizations...focusing on the continuous process of assessment and improvement of a physician over the course of his/her career." (ABMS Press Release, March 2003). What Are the Options for the ABTS? What Are the Options for the ABTS? Top Introduction What Is MOC? What Are the Options... Footnotesp troduction at Is MOC? otnotes Dr Gordon Olinger, immediate past Examination Chair of the ABTS, answered this question as follows: 1 "Accept the status quo, assuming that the present program adequately addresses the issue. 2 Audit practice performance, pitting one physician’s performance against another’s. 3 Change to a program documenting participation in a valid process of assessment and improvement in quality of care as measured against evidence-based standards." (G. N. Olinger, ABMS White Paper.) What Are the Options for the ABTS? Dr Gordon Olinger, immediate past Examination Chair of the ABTS, answered this question as follows: What Are the Options for the ABTS? Dr Gordon Olinger, immediate past Examination Chair of the ABTS, answered this question as follows: 1. "Accept the status quo, assuming that the present program adequately addresses the issue. 1. "Accept the status quo, assuming that the present program adequately addresses the issue. 2. Audit practice performance, pitting one physician’s performance against another’s. 2. Audit practice performance, pitting one physician’s performance against another’s. 3. Change to a program documenting participation in a valid process of assessment and improvement in quality of care as measured against evidence-based standards." 3. Change to a program documenting participation in a valid process of assessment and improvement in quality of care as measured against evidence-based standards."

5 Definitions Adult cardiac surgery is an ethical business that provides potentially dangerous services to under informed, frightened customers Adult cardiac surgery is an ethical business that provides potentially dangerous services to under informed, frightened customers Cardiac surgeons succeed best when they provide optimal information, operations, aftercare, and comfort in a safe environment Cardiac surgeons succeed best when they provide optimal information, operations, aftercare, and comfort in a safe environment

6 Definitions QA is not simply a mechanism for reviewing results after cardiac operations – the m&m model QA is not simply a mechanism for reviewing results after cardiac operations – the m&m model QA is an enabling atmosphere, an attitude, that surrounds all professional interactions with the patient and is refined and reinforced at regular meetings QA is an enabling atmosphere, an attitude, that surrounds all professional interactions with the patient and is refined and reinforced at regular meetings

7 Who is in charge of QA? NOT just physicians and nurses, but every person who serves or touches the patient NOT just physicians and nurses, but every person who serves or touches the patient Every team member must be encouraged to report problems and suggest solutions Every team member must be encouraged to report problems and suggest solutions

8 The QA Team Core group includes includes Core group includes includes all relevant nursing leadership, perfusion, anesthesia, physician assistants, surgeons Invite anyone else whose work touches on a problem area Invite anyone else whose work touches on a problem area The principle is that all stakeholders must be present at one time to solve QA problems The principle is that all stakeholders must be present at one time to solve QA problems

9 The QA Goal The goal is not to assign blame for failure The goal is not to assign blame for failure The goal is to improve performance The goal is to improve performance

10 QA Questions What is happening? What is happening? How does it relate to other aspects of patient care? How does it relate to other aspects of patient care? Is it optimal? Is it optimal? How can it be improved? How can it be improved? Minutes and follow up Minutes and follow up

11 The QA Venue Quarterly meetings to review results, trend, compare to national databases Quarterly meetings to review results, trend, compare to national databases Identify and solve process problems Identify and solve process problems Assess customer satisfaction Assess customer satisfaction

12 Critical QA Jobs Assess, Improve, & Manage: Patient Satisfaction Patient Satisfaction Process (Institutional, Clinical, etc.) Process (Institutional, Clinical, etc.) Outcomes Outcomes Appropriateness of Care Appropriateness of Care Efficiency of Resource Management Efficiency of Resource Management These interlock

13 Patient Satisfaction 1 The patient has a dual role as the object of QA and an important contributor to the QA environment The patient has a dual role as the object of QA and an important contributor to the QA environment

14 Patient Satisfaction 2 Call patients 30 days after discharge. Most are grateful to be alive, so specifically ask what could have been improved Call patients 30 days after discharge. Most are grateful to be alive, so specifically ask what could have been improved Assume that those rare, spontaneous complaints are common problems Assume that those rare, spontaneous complaints are common problems Walk through the patient’s experience Walk through the patient’s experience

15 Process Process refers to the interaction of hospital services with personnel and patients The institution serves by providing a safe, efficient, and pleasant environment The institution serves by providing a safe, efficient, and pleasant environment QA is the best mechanism for caregivers and hospital service providers to solve “process” problems QA is the best mechanism for caregivers and hospital service providers to solve “process” problems

16 Meeting Agenda: Process Issues Meeting Agenda: Process Issues TopicPresenter Operating Room Time EfficiencySurgeons/Fisher Financial ReportAdministration Preventing Medication ErrorsCastro/Pharmacy/ICU Chloraprep Change – New Colored VersionInfection Control Defibrillators bedsideCastro / Gaudiani/ ICU Digital X-Ray SystemRadiology Procainamide MonitoringLaboratory Adequate Blood for Low BSA PatientsLaboratory / Perfusion Override of PyxisICU / Pharmacy No Narcotics for Patients 80+ y.o.ICU / Pharmacy All Valve Patients: Discharge on DyazidePharmacy/ Physician’s Assts.

17 Assessing Results Clinical outcomes must improve and/or meet national standards Clinical outcomes must improve and/or meet national standards Surgeons must lead the QA process Surgeons must lead the QA process

18 QA Ground Rules 1 The patient is never the cause of failure The patient is never the cause of failure The surgeon can be the cause of failure The surgeon can be the cause of failure

19 QA Ground Rules 2 Most failures are the result of personnel problems interacting with process problems Most failures are the result of personnel problems interacting with process problems Personnel problems must be resolved by education Personnel problems must be resolved by education Process problems must be resolved by ruthless diagnosis and intervention Process problems must be resolved by ruthless diagnosis and intervention

20 QA Organization QA manager with data skills and access to surgeons. The “headlights” QA manager with data skills and access to surgeons. The “headlights” 24 hour voic to record quality issues 24 hour voic to record quality issues Regular meetings that delay the surgery schedule so everyone comes Regular meetings that delay the surgery schedule so everyone comes

21 QA Actions Review quarterly results for mortality and morbidity with trending Review quarterly results for mortality and morbidity with trending Compare institutional results to national (STS) results Compare institutional results to national (STS) results Frankly review bad outcomes Frankly review bad outcomes Discuss and resolve QA problems in all categories Discuss and resolve QA problems in all categories

22 Outcomes: Quarterly Summary

23 2005 Case-Mix: Sequoia vs. National

24 Sequoia Hospital Cardiac Surgery Operative Mortality (No Risk Adjustment) STS Overall Mean +2 SD (4.0%) -2 SD (1.8%)

25 Cardiac Surgery: 4th Quarter 2004 Mortality Report NameStatusProc Preop Hx CompsDeath Doe1/6 2 nd Op Urgent82MTVR, Exc 3 pacing wires, Implant Bivent Epicard Pacing system, leads & generator Severe TR, NYHA 3, CAD, severe Pulm HTN, Mean PA 47 PMH: PPM x4-latest 2002, PCI-2002, AVR, MVR-1973, remote CVA EF 65% MRSA pneumonia, RF w/Pk Cr 3.7, DC Cr 1.7 Trans to Fresno Community Hospital POD 20 Expired on POD 34 in Fresno Hospital (Per 30D follow-up) Expired OOH POD 34 Doe1/7 1 st Op Urgent73M MVV, TVR, Maze Severe MR/TR, NYHA 3, Biventricular Failure w QRS=170 ms and greatly enlarged chambers especially on right, Hepatic Dysfunction NIDDM, HTN, Chronic Afib Renal Failure req CVVH, Liver Failure, On/off Ventilator, Aspiration Pneumonia, Sepsis, Sternal dehiscence req rewire, CHB - BiV Pacer placed Multisystem failure ExpiredPOD42

26 Sequoia Hospital Cardiac Surgery Permanent Stroke (No Risk Adjustment) 2000 – % STS Overall Mean +2 SD (2.8%) -2 SD (0%)

27 Stroke Improvement Process TEE on all cases TEE on all cases Selective cerebral perfusion Selective cerebral perfusion Head down coming off bypass Head down coming off bypass Better air maneuvers Better air maneuvers New intraoperative management of severely calcified and grade IV aortas New intraoperative management of severely calcified and grade IV aortas

28 External Review of Appropriateness Cardiac Surgery

29 Rationale for External Review Tenet’s Redding Medical Center Tenet’s Redding Medical Center Blue Cross questioning at least 3 other Tenet facilities Blue Cross questioning at least 3 other Tenet facilities Senate Finance Committee request for Blue Cross data on Tenet hospitals Senate Finance Committee request for Blue Cross data on Tenet hospitals Health plans seek assurance of appropriateness of care for their members Health plans seek assurance of appropriateness of care for their members Employers (PBGH and CalPERS) seek assurance of appropriateness of care for their insureds Employers (PBGH and CalPERS) seek assurance of appropriateness of care for their insureds Current challenges to achieve effective quality assurance/peer review in U.S. hospitals Current challenges to achieve effective quality assurance/peer review in U.S. hospitals

30 Desired Outcome Assurance of appropriateness of cardiac procedures for: Assurance of appropriateness of cardiac procedures for: Cardiac patients and their families Cardiac patients and their families Community at large Community at large Referring physicians/hospitals Referring physicians/hospitals Employers Employers Health plans Health plans Regulatory agencies Regulatory agencies Appreciation on the part of the medical staff for assistance in peer review process Appreciation on the part of the medical staff for assistance in peer review process

31 ACC/AHA Guidelines Class I – conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective Class I – conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective Class II – Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment Class II – Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment Class IIa - Weight of the evidence/opinion is in favor of usefulness/efficacy Class IIa - Weight of the evidence/opinion is in favor of usefulness/efficacy Class IIb - Usefulness/efficacy is less well established by evidence/opinion Class IIb - Usefulness/efficacy is less well established by evidence/opinion Class III – Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective and in some cases may be harmful Class III – Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective and in some cases may be harmful

32 Resource Management

33 Operating Room Time: A Measure of Quality and Resource Management

34 Average Total Operating Room Times for Major Categories

35 Primary Coronary Bypass (n=995)

36 Mitral Valve Repair (n=332)

37 Aortic Valve Replacement (n=535)

38 Aortic Valve Replacement + Coronary Bypass (n = 271)

39 QA Fails When: Surgeons fail to recognize and discuss their own failures Surgeons fail to recognize and discuss their own failures Competing groups use QA to compete Competing groups use QA to compete QA organization is hierarchal QA organization is hierarchal

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


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