DATA AND TRUST IMPROVE SURGICAL OUTCOMES
talking about a bad surgical outcome used to be a strictly confidential matter that could make even the most stoic surgeon bristle. "It was a big deal to ask an attending surgeon to talk openly about a complication," says former chair of surgery Sean J. Mulvihill, M.D. "There was a lot of fear."
So when Mulvihill announced to the department that they were going to document every complication and adverse outcome, discuss them openly at weekly meetings, and report them to a national database, there was some pushback. To allay the angst, Mulvihill made his intentions perfectly clear: "I told my staff that this wasn't about getting anyone fired. It was about quality improvement."
Mulvihill proved his point by openly discussing his own complications during weekly Morbidity and Mortality (M & M) meetings, and changed the word complication to occurrence. "The tone of the conversation was never punitive," says surgical clinical reviewer Judy Larsen, R.N., who was tasked with the delicate job of collecting and distributing the data to the surgeons and bringing every occurrence to M & M meetings. "It was always educational."
"I told my staff that this wasn't about getting anyone fired. It was about quality improvement."
Mulvihill wanted his department to lead the way in establishing greater transparency to improve surgical outcomes. The new protocols were part of joining a pilot program to test the National Surgical Quality Improvement Program (NSQIP) in the private sector. In 2001, University Hospital was one of 18 hospitals to join NSQIP, which was developed by the Department of Veterans Affairs and the American College of Surgeons.
A few key factors helped create buy-in among his staff. The metrics were created and defined by surgeon colleagues. Definitions of outcomes were specific and consistent. The data were impartially analyzed through a central database and risk-adjusted to account for sicker patients. In other words, NSQIP created meaningful data that the faculty trusted. The most persuasive factor, however, was seeing firsthand how the process helped improve patient care.
When NSQIP data showed that the surgery department was a high outlier in postoperative urinary tract infections (UTIs), Rob Glasgow, M.D., section chief of gastrointestinal surgery, led a multidisciplinary team to make procedural changes in catheter management. The next time NSQIP data came out, our surgeons and staff had reduced postoperative UTIs by 75 percent. By NSQIP standards, we went from a 10 (the worst) to a 4 (better than half of the participating hospitals). "This was about real people having better outcomes," says Glasgow, who is now the NSQIP Surgeon Champion. "We had to create a culture of critical appraisal to know where we could improve."
The department took transparency even further by opening its weekly M & M meetings to residents, nurses and students. "It's an excellent teaching opportunity," says Larsen. "And now it's just automatically assumed that when we have an outlier, not just one faculty member but a whole team of people, including residents, will take it on," says Larsen.
The department also expanded the conversation to include issues of professionalism, honest disclosure and positive communication to engender trust in patients. As the move to transparent quality improvement became a fully accepted part of the department's culture, uncertainty and fear were replaced with a common sense of purpose that everyone could embrace. "The essence of quality improvement is something we all buy into," says Mulvihill, who is now the associate vice president for clinical affairs and CEO of the physician group. "At the end of the day, we all want better outcomes. We all want to be proud of what we do."