College of Surgeons San Diego Inspiring Quality Forum P2

San Diego is probably a community in the country where they used these principle in developing The Trauma Center 30 years ago.  It has really been a model for how we look at this.  The trauma system is truly an example of disease management, and these principles are embedded in this concept.  I think you’re all familiar with the wondering impact this can have.  That graph in the right lower part of the slide is the original graph that compared the no trauma system.  Preventable mortality was reduced and has held at that threshold for the last 32 years.  In a way, this is our good housekeeping seal of approval based on these quality pillars, and that’s going to be the core of the message this morning.

Now, there are two major pressures on all of us in medicine today, and the first is the quality movement.  To a certain extent, this started with the Institute of Medicine report To Err is Human.  It was championed through the subsequent report Crossing the Quality Chasm.  I think that led to the proliferation of quality measurement efforts, programs, and a lot of confusion.  Actually, in the last year, there has been consolidation and alignment, at least in the federal level, and the evidence for that is in this slide. The top there is the National Quality Strategy that comes out of Secretary Sevilla’s office.  You see the emphasis is on improving care, better care, healthy people in communities.  So, prevention efforts and making that portable.

When you look at the largest pair, CMS, they are reflecting exactly the same philosophy through the Triple Aim of Don Brewer.  He’s no longer the administrator, but the impact that his philosophy had where CMS is headed is, again, to improve the experience of care, improve the health of populations, and reduce per capita cost.  Finally, the same organization, The Institute of Medicine, that started the quality chasms, led to the original To Err is Human report, in the last two years, has defined the concept of a learning health care system as the ultimate goal with the concept and contextualization of evidence.  Their goal is to have decision making by 2020, 90% of the time, reflect the best evidence.

That’s one huge change that we’re under.  Now, who has a learning health care system today?  I would argue that the American College of Surgeons is well on its way to being a prototype in medicine for that.  We use best evidence to establish surgical care standards.  We have then disciplined ourselves to measure outcomes through databases that are designed to assure performance of standards.  When we reflect on that data and find deviations, we use that data to reconfigure clinical trials.  The introduction of new technology is able to be done through this kind of process.  That, again, redefines best evidence.

So, this concept of a continuous loop of continuous quality improvement is embedded here in the way we think and in our programs as well as in many of your hospitals.  The other major pressure that we’re under is the finally one, and we’ve all seen these slides, 2020, $4.5 trillion, 19% of GDP.  Look at it another way, we currently, with all of our taxation opportunities, generate at a federal level, generate 18% of the gross national product.  We can consume with Medicare, social security, and interest on our debt, 16%.  If you think about that, the real dilemma that we have is without raising our taxes or without changing the revenue structure that we currently have, we’re using most of our health care dollar or most of our federal dollar for healthcare delivery and other entitlements.

The problem is that, then, is making us make choices that we as physicians really need to appreciate if we’re going to participate in this.  Now, Uwe Reinhardt who’s a somewhat controversial economist at Princeton puts it this way, that the net social value from a health system really equals the gross value of the actual health care that you give to patients minus the opportunity cost to society.  A lot of what you’re seeing in Congress being frozen right now is how much we’re going to be putting in health care relative to research, relative to infrastructure to roads, and all the other things that the government does.  I’m not sure we have an answer to that, but I think that’s fundamentally important for us to understand.

Our message is that in the American College of Surgeons, we’ve got something to bring to the table, and we’re going to show you an example of this.  We’ve found a way to lower costs and increase quality to, Brent Eastman’s point, the value equation.  It’s based on this program called NSQIP. Many of you in San Diego are participants of this, and I want to congratulate you on the forward thinking to subject yourself to measurement of surgical programs and use this as a tool to improve.

Now, the actual premise, if you’re not familiar, with NSQIP is based on this slide.  We refer to this as a caterpillar diagram, and it’s simply shows the performance, in this case, of 450 hospitals against some outcome.  This could be surgical infection.  This could be DVT prophylaxis.  What you see in this is right there on red, the hospitals that are against the standard are performing less than what you would expect.  In green, on the left, are hospitals that are performing better.

When you share this kind of data with physicians, it’s hard wired into our psyche, if you will, to try to improve if you’re in that red zone.  Now, you can say that, and we all know how we would react if our performance in our practice showed a higher-than-expected surgical infection rate.  The data shows this actually works.

Here’s a very important study by Bruce Hall and Cliff Ko who’ve been fundamentally involved in the development of this program.  They studied over 100 hospitals, looked at it over three years, and showed that by participating in this kind of effort, 82% reduction in complications, reduction in mortality.  That worked out to about one complication per hospital per day for an average 400-bed hospital.  When you couple that with the cost of a complication which is probably conservative at about $11,000, each hospital then is actually having a cost savings of $3-5 million dollars.  You spread that across all the hospitals in the United States, and you’re talking about a significant contribution to this health care dilemma of billions of dollars in cost reduction.

Now, the other important aspect of this is this drives a conversation, and one of the things we’re hoping to do with these forums is bring you a little closer as a community in creating collaboratives such as we have in Tennessee or Michigan.  These collaboratives, again, are based on the database, but what they do is they foster people coming together, sharing data with one another and then finding solutions and common problems to work together on overall to improve.  Again, San Diego has been an incredible leader in this regard, and again, I’ll fall back to the trauma system.

In San Diego County, there has been a conversation for 30 years between the trauma centers and the community through the medical audit committee, which is really the prototype model for these collaboratives.  I’m sure, with time, you will move to this in a broader fashion.

Well, the surgeon of the future and probably physicians in general are really going to be parts of teams.  They’re going to be leading safe, high performance teams, increasing the integration of surgical and non-surgical skills.  I had a chance to see the hole in the ground for your new cardiovascular center.  It’s a wonderful example for this, and we’re increasingly all going to be parts of systems of care.  We’re going to be a held to a basis of evidence-bases more than in the past, outcomes data, which will reporting.  These are really are givens today.  We’re not there yet, but I think it’s the direction I think that health care is going.  So, we’ve really got to be prepared to participate, and again, NSQIP program I think is a wonderful example of that.

Now, I just want to end a little bit on another topic which is really quality in education.  How do you know a surgeon is competent to do a new procedure?  That’s a real challenge because in the past, we’ve followed the “See-one-do-one-to-each-one” model, and that’s not objective and precise enough particularly with the concepts that are being put forth with new technology.

So, we’ve extended this concept of inspiring quality in objectifying and verifying education through the concept of accredited education institutes, and these are designed to be throughout the country and be places where surgeons can learn new skills and have validated that their learning has been appropriate.  There’s a wonderful example again in San Diego UCSD that Dr. Talamini and his colleagues have developed, The Center for the Future of Surgery.  These are the kind of things, in addition to the quality programs that are hospital-bases, that really need to be a part of our health care though process going forward.

In another way, we’re redefining our concept of professionalism.  Whereas 100 years ago, the use of autonomy, authority, and assertion with surgeons has really evolved into further collaboration, evidence-bases, measurement, transparency, and really, we’re redefining our profession on behalf of our patients as accountability.  This gets back, then, to the coupling of this quality initiative to our advocacy efforts.

To that end, we’ve developed the inspiring quality campaign, higher standards and better outcomes.  We’ve taken this to Capitol Hill as a kickoff in May.  We’ve had desktop conversations with many legislators to get them to understand this, and it’s been very interesting to see the effect that this has had instead of just going in and taking about payment reform or medical liability reform.  Leaders at the legislative level are listening.  They are interested in what physicians have to say, particularly when you talk about things that ultimately affect patients.

We’ve started these quality forums as another way to engage, at a more local level, this conversation, and we would encourage you to continue this in the San Diego community as well.  We’re spreading this across the country as you can see.   We’ve developed a lot of tools and ways to help you and assist you both in your hospital and in your community, and these are all available to you.  We can provide them through the web or just simply by asking.

Finally, I’d just like to thank Dr. Eastman for his contributions in San Diego, but also the fact that he is now the president-elect of the American College of Surgeons.  It just shows you what outstanding leadership he’s not only provided in San Diego, but he’s now going to provide now literally to the world.

I want to end with a little summary video that puts it together for you and gives our core message.  I also want to thank our colleagues form Weber Shandwick for helping us put these things together so we can just click on that.


Again, Brent.  Thanks very much for the opportunity to be with you today.


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