Strategies for improving surgical quality:
A conceptual framework
Justin B. Dimick, MD, MPH
Associate Professor of Surgery
Department of Surgery
University of Michigan
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
Performance varies
Activity
Waves of Change
Health System Strategic Activity
2010
2011
2012
2013
Physician Alignment
2014
Quality Improvement
2015
2016
2017
2018
At-Risk Business Models
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
Myaclinical trajectory
Is this
safety
problem?
Safety of bariatric surgery in the United States
0.09
Serious Complication Rate
0.08
Non-Medicare
0.07
Medicare
0.06
0.05
0.04
0.03
0.02
0.01
0.00
2004
2005
2006
2007
Time (Year)
Dimick JB, et al. JAMA 2013
2008
2009
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)
What are the different strategies
for improving surgical quality?
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
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)
Sort yourselves
YELLOW
RED
GREEN
BLUE
Collaborate
Control
Create
Compete
Innovative
“Out of the
box” thinkers
Collaborate
Control
Create
Compete
Focus on
ideas
Warm and cuddly
Strong mentoring
skills
Innovative
“Out of the
box” thinkers
Focus on
relationships
Focus on
ideas
Collaborate
Control
Create
Compete
Warm and cuddly
Strong mentoring
skills
Innovative
“Out of the
box” thinkers
Focus on
relationships
Focus on
ideas
Collaborate
Control
Create
Compete
Driven
Competitive
“Must win”
attitude
Focus on
results
Warm and cuddly
Strong mentoring
skills
Innovative
“Out of the
box” thinkers
Focus on
relationships
Focus on
ideas
Rules and
regulations
Policy
adherence
Focus on
compliance
Collaborate
Control
Create
Compete
Driven
Competitive
“Must win”
attitude
Focus on
results
Collaborate
Control
Create
Compete
Improving quality = adding value
New
technology &
Innovative
surgical
approaches
Physicians
working together
Focus on building
relationships
Collaborate
Policies
mandating
physician
compliance
Focus on
compliance
with standards
Control
Create
Compete
Focus on new
ideas
Physicians
competing with
each other
Focus on the
best outcomes
Brainstorm
Compete
Create
• What are the best
ways to improve
surgical quality by
focusing on
competition?
CMS national coverage decision
Complications with bariatric surgery in Michigan
Birkmeyer NJO et al., JAMA, 2010
COEs vs. non-COEs, 12 large States
Odds Ratio for Adverse Outcome,
COE vs. non-COE (95% CI)
Adverse outcomes
Any complications
Serious complications
Reoperations
Adjusting for patient characteristics,
procedure type, and time trends
(95% CI)
0.97 (0.90,1.06)
0.92 (0.85,1.01)
1.11 (0.92,1.34)
Dimick JB, et al. JAMA 2013
Implementation of the COE policy
National Coverage Decision
Serious Complication Rate
0.09
0.08
Non-Medicare
0.07
Medicare
0.06
0.05
0.04
0.03
0.02
0.01
0.00
2004
2005
2006
Time (Year)
Dimick JB, et al. JAMA 2013
2007
2008
2009
Challenges of using competition
• Sometimes hard to know who’s “the best”
• Patient access issues
• Highly polarizing
With competition there is tension with
collaboration
Brainstorm
Create
• What are the best
ways to improve
surgical quality using
innovation and new
ideas?
Lower risk procedures
Changes in procedure use
Procedure type:
LRYGB
ORYGB
LAGB
Other
NCD
70%
% of Patients
60%
50%
40%
30%
20%
10%
0%
2004
2005
2006
Time (Year)
2007
2008
2009
New technology
Band erosion rates of 30% and removal rates of 50%
Downsides of new technology
• Unintended consequences
– Safer but less effective?
• Widespread adoption without adequate
evidence
With innovation there is tension with
standardization
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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
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
Health Affairs, April, 2011
Brainstorm
Control
• What are the best
ways to improve
surgical quality by
focusing on
compliance?
Standardizing care across Michigan:
Optimizing VTE prophylaxis for
bariatric surgery
Use of Pre-Operative Heparin, 2008
VTE rates by Type of Heparin Used
Birkmeyer NJO et al., Arch Surg, 2013
VTE Risk Calculator and Treatment
Guidelines
Rates of VTE Guideline Adherence Over
Time
*Based
on random site audit of 1,148 charts to verify VTE prophylaxis data
Temporal Trends in Rates of VTE and
Death
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
Brainstorm
Collaborate
• What are the best
ways to improve
surgical quality by
focusing on
relationships?
Modified OSATS Global Rating Scale of Operative Performance
Performance rating: 1 (Poor performance) – 5 (Excellent performance)
Category
Respect for Tissue
1
Time and Motion
Frequently used
unnecessary force on
tissue or caused
damage by
inappropriate use of
instruments
1
2
1
2
3
2
Efficient time/motion
but some unnecessary
moves
3
2
Competent use of
instruments but
occasionally appeared
stiff or awkward
3
Repeatedly makes
tentative or awkward
moves with instruments
Flow of Operation
1
Frequently stopped
operating or needed to
discuss next move
Exposure
1
2
1
Chief resident
3
4
5
4
Economy of
movement and
maximum efficiency
5
Fluid moves with
instruments and no
awkwardness
4
5
4
Obviously planned
course of operation
with effortless flow
from one move to the
next
5
Good exposure for
most of the key steps of
procedure
2
3
Average bariatric
surgeon
5
Consistently handled
tissues appropriately
with minimal damage
Demonstrated ability
for forward planning
with steady progression
of operative procedure
Poor retraction
frequently causing poor
visualization or
awkward tissue
alignment
Overall Technical Skill
4
Careful handling of
tissue but occasionally
caused inadvertent
damage
Many unnecessary
moves
Instrument Handling
3
Highly skilled
retraction. Makes
operation appear easy
4
5
Master bariatric
surgeon
Average of Six Ratings of Technical Skill
Video # =
N Raters =
Note: ◊ represents the mean; bars extend from mean ± standard
Average of Six Ratings of Technical Skill
Bottom
Middle
Video # =
N Raters =
Note: ◊ represents the mean; bars extend from mean ± standard
Top
p<0.001
p<0.001
Surgeon Skill:
p=0.001
Rafael Nadal
Itzhak Perlman
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
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
Collaborative quality
improvement is a
powerful tool for
large-scale quality
improvement but its
challenging to
engage surgeons
Efforts at
compliance with
standards and
work but generally
set a low bar on
performance
Collaborate
Control
Create
Compete
Adoption of
new technology
will continue to
advance safety
but needs to be
evidence-based
Center of
excellence
models will
work but only
for few rare
conditions
The secret to using each strategy lies in
finding balance with the opposite quadrant
Improving quality = adding value
New
technology &
Innovative
surgical
approaches
Physicians
working together
Focus on building
relationships
Policies
mandating
physician
compliance
Focus on
compliance
with standards
Collaborate
Create
Control
Compete
Focus on new
ideas
Physicians
competing with
each other
Focus on the
best outcomes
Our responsibility
Activity
External pressures mounting
2010
2011
2012
2013
Physician Alignment
2014
Quality Improvement
2015
2016
2017
2018
At-Risk Business Models
Physician-led Quality Improvement
Outcomes measurement & analysis
Physician collaboration on best practices & CDS
Reduced variation in quality
Lower, more predictable costs At-Risk Business Models
Physician Alignment
Health systems acquiring practices, hospitals
Physician selection – volume, quality, cost
Financial incentives/compensation aligned
Management coordination
Quality Bonuses and Penalties
Episode Payment Bundles
Capitation / Population Health
Member Claims Analysis
But we’ve done it before.
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)