Quality Assurance for Cardiac Surgery

1. California Society of Thoracic Surgeons Annual Meeting Stanford University, July 30th, 2005 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

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

3. "A comprehensive process...based on quality standards set bymember boards and other standard-setting organizations...focusingon the continuous process of assessment and improvement of aphysician over the course of his/her career." (ABMS Press Release,March 2003). 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." • Dr Gordon Olinger, immediate past Examination Chair of the ABTS,answered this question as follows: • 1 "Accept the status quo,assuming that the present programadequately addresses the issue. • 2 Audit practice performance, pitting one physician’sperformance against another’s. • 3 Change to a programdocumenting participation in a valid processof assessment andimprovement in quality of care as measuredagainst evidence-basedstandards." (G. N. Olinger, ABMS WhitePaper .)

4. "A comprehensive process...based on quality standards set bymember boards and other standard-setting organizations...focusingon the continuous process of assessment and improvement of aphysician over the course of his/her career." (ABMS Press Release,March 2003). Maintenance of Certification: A Message from the American Board of Thoracic Surgery (ABTS)* William A. Gay, Jr, MD* • 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. • 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." • Dr Gordon Olinger, immediate past Examination Chair of the ABTS,answered this question as follows: • 1 "Accept the status quo,assuming that the present programadequately addresses the issue. • 2 Audit practice performance, pitting one physician’sperformance against another’s. • 3 Change to a programdocumenting participation in a valid processof assessment andimprovement in quality of care as measuredagainst evidence-basedstandards." (G. N. Olinger, ABMS WhitePaper .)

5. Definitions • 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

6. Definitions • QA is not simplya 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

7. Who is in charge of QA? • 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

8. The QA Team • Core group includes includes all relevant nursing leadership, perfusion, anesthesia, physician assistants, surgeons • 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

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

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

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

12. Critical QA Jobs Assess, Improve, & Manage: • Patient Satisfaction • Process (Institutional, Clinical, etc.) • Outcomes • Appropriateness of Care • 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

14. Patient Satisfaction 2 • 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 • 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 • QA is the best mechanism for caregivers and hospital service providers to solve “process” problems

16. Meeting Agenda: Process Issues

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

18. QA Ground Rules 1 • The patient is never 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 • Personnel problems must be resolved by education • Process problems must be resolved by ruthless diagnosis and intervention

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

21. QA Actions • Review quarterly results for mortality and morbidity with trending • Compare institutional results to national (STS) results • Frankly review bad outcomes • 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) 2000- 2004 +2 SD (4.0%) 3.4 STS Overall Mean -2 SD (1.8%)

26. Sequoia Hospital Cardiac Surgery Permanent Stroke (No Risk Adjustment) 2000 – 2004 +2 SD (2.8%) 1.6% STS Overall Mean -2 SD (0%)

27. Stroke Improvement Process • TEE on all cases • Selective cerebral perfusion • Head down coming off bypass • Better air maneuvers • 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 • Blue Cross questioning at least 3 other Tenet facilities • Senate Finance Committee request for Blue Cross data on Tenet hospitals • Health plans seek assurance of appropriateness of care for their members • 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

30. Desired Outcome • Assurance of appropriateness of cardiac procedures for: • Cardiac patients and their families • Community at large • Referring physicians/hospitals • Employers • Health plans • Regulatory agencies • 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 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 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

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 • Competing groups use QA to compete • QA organization is hierarchal

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