Strategies for improving surgical quality: A conceptual framework

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 ChangeHealth System Strategic Activity 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 GREEN YELLOW BLUE RED

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 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 • What are the best ways to improve surgical quality by focusing on relationships? Collaborate