Transcript Document

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
Quality Assurance is the largest structural
problem facing cardiac surgery
 Recertification
 Patient Safety
 Training
 Public Responsibility
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."
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."
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
Definitions


QA is not simply a 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
Who is in charge of QA?

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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
The QA Team

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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
The QA Goal

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The goal is not to assign blame for failure
The goal is to improve performance
QA Questions

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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
The QA Venue



Quarterly meetings to review results, trend,
compare to national databases
Identify and solve process problems
Assess customer satisfaction
Critical QA Jobs
Assess, Improve, & Manage:
 Patient Satisfaction
 Process (Institutional, Clinical, etc.)
 Outcomes
 Appropriateness of Care
 Efficiency of Resource Management
These interlock
Patient Satisfaction 1

The patient has a dual role as the object of QA
and an important contributor to the QA
environment
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
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
Meeting Agenda:
Process Issues
Topic
Presenter
Operating Room Time Efficiency
Surgeons/Fisher
Financial Report
Administration
Preventing Medication Errors
Castro/Pharmacy/ICU
Chloraprep Change – New Colored Version
Infection Control
Defibrillators bedside
Castro / Gaudiani/ ICU
Digital X-Ray System
Radiology
Procainamide Monitoring
Laboratory
Adequate Blood for Low BSA Patients
Laboratory / Perfusion
Override of Pyxis
ICU / Pharmacy
No Narcotics for Patients 80+ y.o.
ICU / Pharmacy
All Valve Patients: Discharge on Dyazide
Pharmacy/ Physician’s Assts.
Assessing Results
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Clinical outcomes must improve and/or meet
national standards
Surgeons must lead the QA process
QA Ground Rules 1

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The patient is never the cause of failure
The surgeon can be the cause of failure
QA Ground Rules 2

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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
QA Organization
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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
QA Actions

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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
Outcomes:
Quarterly Summary
2005 Case-Mix:
Sequoia vs. National
80%
74%
70%
60%
50%
Nat'l
SEQ
40%
30%
29%
27%
24%
20%
10%
0%
13%
11%
8%
7%
CAB
AVR
3%
4%
MVR
MVV
Other
Sequoia Hospital Cardiac Surgery
Operative Mortality (No Risk Adjustment)
2000- 2004
5.0%
SEQUOIA
+2 SD (4.0%)
4.0%
STS 2003 (3.4%)
3.8%
+2 SD 4.0%
-2 SD 1.8%
3.0%
2.9%
2.5%
2.0%
2.9%
2.4%
3.4 STS
Overall
Mean
-2 SD (1.8%)
1.0%
0.0%
2000
2001
2002
2003
2004
Cardiac Surgery: 4th Quarter 2004
Mortality Report
Name
Status Proc
Preop Hx
Comps
Death
Doe
1/6
2nd Op
Urgent
82M
TVR,
Exc 3
pacing
wires,
Implant
Bivent
Epicard
Pacing
system,
leads &
generator
Severe TR, NYHA 3,
CAD, severe Pulm
HTN, Mean PA 47
PMH: PPM x4-latest
2002, PCI-2002, AVR,
MVR-1973, remote CVA
EF 65%
MRSA pneumonia, RF
w/Pk Cr 3.7, DC Cr 1.7
Expired
OOH
POD 34
MVV,
TVR,
Maze
Severe MR/TR, NYHA
3, Biventricular Failure
w QRS=170 ms and
greatly enlarged
chambers especially on
right, Hepatic
Dysfunction NIDDM,
HTN, Chronic Afib
Doe
1/7
1st Op
Urgent
73M
Trans to Fresno
Community Hospital
POD 20
Expired on POD 34 in
Fresno Hospital (Per
30D follow-up)
Renal Failure req
CVVH, Liver Failure,
On/off Ventilator,
Aspiration Pneumonia,
Sepsis, Sternal
dehiscence req rewire,
CHB - BiV Pacer placed
Multisystem failure
Expired
POD
42
Sequoia Hospital Cardiac Surgery
Permanent Stroke (No Risk Adjustment)
2000 – 2004
3.5%
+2 SD (2.8%)
3.0%
2.5%
SEQUOIA
STS 2003
2.7%
+2 SD 2.8%
-2 SD 0%
2.0%
1.8%
1.5%
1.2%
1.1%
1.0%
0.8%
0.5%
0.0%
2000
2001
2002
-2 SD (0%)
2003
2004
1.6% STS
Overall
Mean
Stroke Improvement Process

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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
External Review of
Appropriateness Cardiac Surgery
Rationale for External Review
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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
Desired Outcome

Assurance of appropriateness of cardiac procedures
for:
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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
ACC/AHA Guidelines

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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

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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
Resource Management
Operating Room Time:
A Measure of Quality and
Resource Management
Average Total Operating Room
Times for Major Categories
5:02
OR Time (H:MM)
4:48
4:33
CAB+AVR
CAB
4:19
AVR
4:04
MVV
3:50
3:36
3:21
3:07
1998
1999
2000
2001
2002
2003
2004
Primary Coronary Bypass
(n=995)
OR Time (H:MM)
+/- SD
5:45
5:16
4:48
4:19
3:50
3:21
2:52
1998
1999
2000
2001
2002
2003
2004
Mitral Valve Repair
(n=332)
OR Time (H:MM)
+/- SD
5:45
5:16
4:48
4:19
3:50
3:21
2:52
1998
1999
2000
2001
2002
2003
2004
Aortic Valve Replacement
(n=535)
OR Time (H:MM)
+/- SD
5:45
5:16
4:48
4:19
3:50
3:21
2:52
1998
1999
2000
2001
2002
2003
2004
Aortic Valve Replacement +
Coronary Bypass
(n = 271)
5:45
OR Time (H:MM)
+/- SD
5:16
4:48
4:19
3:50
3:21
2:52
2:24
1998
1999
2000
2001
2002
2003
2004
QA Fails When:

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Surgeons fail to recognize and discuss their own
failures
Competing groups use QA to compete
QA organization is hierarchal
Conclusion

Each man’s death diminishes thee…so ask not
for whom the bell tolls…it tolls for thee