1. Strategies for improving surgical quality: A conceptual framework
Justin B. Dimick, MD, MPH
Associate Professor of Surgery
Department of Surgery
University of Michigan

2. 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

3. Performance varies

4. 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

5. Is this a safety problem?
My clinical trajectory

7. 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

8. 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)

9. What are the different strategies for improving surgical quality?

10. 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

11. 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)

12. Sort yourselves
YELLOW
GREEN
RED
BLUE

14. Innovative
“Out of the box” thinkers
Focus on ideas

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

16. 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

17. 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

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

22. CMS national coverage decision

23. Complications with bariatric surgery in Michigan
Birkmeyer NJO et al., JAMA, 2010

25. 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

26. Implementation of the COE policy
Dimick JB, et al. JAMA 2013

27. Challenges of using competition
Sometimes hard to know who’s “the best”
Patient access issues
Highly polarizing
With competition there is tension with collaboration

28. Brainstorm
What are the best ways to improve surgical quality using innovation and new ideas?
Create

30. Lower risk procedures

31. Changes in procedure use

32. New technology

34. Band erosion rates of 30% and removal rates of 50%

35. Downsides of new technology
Unintended consequences
Safer but less effective?
Widespread adoption without adequate evidence
With innovation there is tension with standardization

36. 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

37. 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

40. Health Affairs, April, 2011

41. Brainstorm
Control
What are the best ways to improve surgical quality by focusing on compliance?

43. Standardizing care across Michigan: Optimizing VTE prophylaxis for bariatric surgery

44. Use of Pre-Operative Heparin, 2008

45. VTE rates by Type of Heparin Used
Birkmeyer NJO et al., Arch Surg, 2013

46. VTE Risk Calculator and Treatment Guidelines

47. Rates of VTE Guideline Adherence Over Time
*Based on random site audit of 1,148 charts to verify VTE prophylaxis data

48. Temporal Trends in Rates of VTE and Death

49. 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

50. Brainstorm Collaborate
What are the best ways to improve surgical quality by focusing on relationships?
Collaborate

53. 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

54. Average of Six Ratings of Technical Skill
Video # =
N Raters =
Note: ◊ represents the mean; bars extend from mean ± standard error.

55. Average of Six Ratings of Technical Skill
Bottom
Middle
Top
Video # =
N Raters =
Note: ◊ represents the mean; bars extend from mean ± standard error.

56. p<0.001
p<0.001
Surgeon Skill:
p=0.001

57. Rafael Nadal
Itzhak Perlman

58. 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

59. 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

60. 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

61. 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

62. Our responsibility

63. 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

64. But we’ve done it before.