1. How to Build an Effective Surgical Quality Program J.H. “Pat” Patton, Jr., MD, FACS Jennifer Ritz, RN, BSN

2. 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

3.  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

4. HFH 2006 NSQIP Data

5. HFH

6. The 5 Phases of NSQIP Grief 1.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

7. 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”

8. “low hanging fruit”  VTE incidence, inconsistent prophylaxis

9. Comparison of HFH to NSQIP database: 5/29/06 – 12/1/06 Percent

10. Comparison of HFH to NSQIP database: 01/01/07 – 01/31/08 Percent

11. 2007 NSQP DATA HFH

12. 2007-2008 NSQIP Data HFH

13. 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. 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. 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. 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. 17 Project Dashboard

19. 19 Portion of Dashboard

20. Project Dashboard

22. 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 Hospitals Vic 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. 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. 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.

25. 25 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!

26. 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) 26

27. 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

28. 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 28 From Barry Silbaugh, MD, ACPE

29. The Safe Path 29

30. The Unsafe Path 30

31. ACTIVE AND PASSIVE LEADERSHIP 31 GOOD BADPASSIVEACTIVE Empowers others Won’t micromanage Methodical progress Indecisive Risk averse Seems confused Commands/Acts Charts the course Thinks ~fast~forward Ego driven Alienates subordinates High Emotions

32. ACTIVE AND PASSIVE LEADERSHIP 32 GOOD BADPASSIVEACTIVE Empowers others Won’t micromanage Methodical progress Indecisive Risk averse Seems confused Commands/Acts Charts the course Thinks ~fast~forward Ego driven Alienates subordinates High Emotions Champion vs. Authority Champion vs. Authority Influence vs. Control Influence vs. Control Persuasion vs. Coercion Persuasion vs. Coercion

33. 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 33

34. 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 34

35. "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

36. How Surgeons Want To See Their Leaders  Advocate  Protector  Communicator  First among equals, “not one millimeter above” 36

37. 37 Challenges

38. 38 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 functions 2.Controls a related set of workers 3.Is the sum of all the parts - Newtonian Systems 4.Supports a structured/familiar Organization 5.Operates under a defined set of principles 6.Is tied together by a unique culture LEADING IN THE SILO

39. 39 Meta-Leadership Department Chairs Surgical Services Big picture Big picture Multi-dimensional perspective Multi-dimensional perspective Comfortable with the unfamiliar Comfortable with the unfamiliar Recognize cultural value Recognize cultural value Can integrate diverse goals Can integrate diverse goals COMPLEX ADAPTIVE SYSTEMS More than the sum of the individual parts

40. 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 40

41. 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 41

42. 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? 42

43. 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 43

44. 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 44