College of Surgeons San Diego Inspiring Quality Forum P3

Dr. Eastman:

While I’m thanking Dr. Hoyt, in the interest of time, why doesn’t the panel assemble on the podium?  Dr. Hoyt, thank you.  Dr. Feinstein might have been good, but you were better.  David Hoyt has always inspired me, and I guess what I would like to say, Dr. Cochrane, you know Dr. Hoyt as a physician-scientist, made numerous contributions.  He could be up here just as well talking about his contributions in surgery, critical care, and the immunology and understand the immunology of the injured patient.  So, I hope you are as proud of David Hoy as we are with his contributions.  David, he gives you two thumbs up.  Thank you very much, David.

What I like about this is the concept we hear over and over again, evidence-based.  How many people in this room are operating surgeons?  Now, if you trained when I did or in that realm, it was not evidence-based.  It was imminence-based, and you did what the professor told you to do.  We have some imminence-based surgeons on the panel today, Dr. Dillehan [29:54].  We’ll see if he has transformed himself.

So, in the interest of time, I’m not going to go through the distinguished and impressive bios of the panelists, but rather, and we’ve rehearsed actually this morning, each panelist is going to introduce himself, what they are, what they do.  Then, they have five minutes to give their summary of what we’re talking about today.  Hopefully, we’ll have a little time at the end.  We’ll finish on time to do that.  So, we’ll start with Chris Van Gorder, and I am pleased that Chris was willing to come today.  He was supposed to be at several other places, but I think it shows his dedication and commitment to quality as you’ll hear it from the position of a CEO.  It is not just we doctors and physicians that are interested in the quality of health care.  Chris?


Chris Van Gorder:

Thank you, Brent.  Well, first of all, thank you to all of you.  It’s not every day that a hospital administrator is invited to speak with an illustrious group of surgeons and physicians.  So, I am honored to be a part of this panel today.  I am the president and CEO of Scripps health, but I am also the immediate past chairman, which is the president-equivalent, for ACHE, the American College of Healthcare Executives.  In that role in the last seven years, actually, in the Board of Governors for ACHE, I’ve had the chance to travel around the world and certainly across the country.   It’s been fascinating for me, whether it was South America or Europe or anywhere in between.

There were three issues in every country, regardless of fee-for-service system, a socialized universal health care system, or no system at all.  The three issues everyone is talking about is cost, quality, and access.  It’s as simple as that.  So, there is no perfect system anywhere in the world, and I think everybody is trying to do what the American College of Surgeons is doing right now, finding more ways of creating value for our patients and our society by finding ways to lower costs and improve quality.

We clearly have a broken health care system, and health care has been unaffordable in our country for a long, long time.  I mean, frankly, it was just screened or veiled by our national fiscal and tax policies, but not now our debt ceiling has become a real national issue, we can’t be high on the fact that health care is unaffordable in our country any longer.

One of the things I try really hard not to do is criticize the federal HHS or the CMS.  They do a lot of audits.  Having said that, the Better for Care Innovation is trying to come up with a solution to all of our health care problems by coming up with a flavor of the week.  It seems like almost weekly that they come out with a new model for health care delivery.  To date, none of those have actually reduced costs and created great value.

So, I believe the American College of Healthcare Executives, and I’m here really to speak for them today, but I believe as healthcare professionals, surgeons, physicians, and healthcare administrators, the solutions are going to be found with us.  They are not going to be found by the government, and so I think in a lot of the initiatives going on right now, the ACS is very important.

At Scripps, what we’re trying to do is follow a couple of different paths.  One is to redesign healthcare delivery system ourselves.  I often say we’re in a sick business.  Historically, if you aren’t sick, we’re out of business, and I think we’re shifting now to become a healthy business by trying to focus on the ambulatory piece of our business which has been fragmented and disconnected from the inpatient piece forever.  Connecting these pieces, focusing on populations but at the same time not forgetting that healthcare is delivered to individuals one person at a time.

That focuses back a bit on our genomics work that we’re doing.  We know for a fact that there’s a lot of therapies and pharmaceuticals, for example, that are prescribed to populations because that’s the best knowledge we have, but maybe because of the genomic makeup of an individual, that direction can even be metabolized.  We believe there are billions of dollars of health care waste.  So, if we could actually harness the genome and customize our individualized care, we could reduce cost.

So, combining a redesigned delivery system with focusing on individual care for patient population is really the way to go.  Then, we need to reduce what we call non-value added variation.  Very important and what we’ve done is we’ve literally flipped our company on the inside.  We pulled the chief operating officers out of the hospital, responsible now for a function, be it imaging or something like that, across the entire healthcare system, all of the hospitals and ambulatory combined, looking for a non-value added variation.  We believe we can improve quality, reduce cost, create more value for our patients and for the organization if we do that.

Then, the IT piece is important.  If we don’t have data to give to our doctors, and to all the folks that we have in our organization working on quality, we can actually not improve the quality.  So, in this clip, Ralph Billy, Dr. Dilly in our organization, really took the lead on this clip as one of those tools we have to use.

So, let me just conclude with Ian Morrison who’s a futurist.  If you know Ian, he’s a Scotsman and a brilliant futurist, and back in September, when the healthcare administrators were complaining about these changes that were coming, he just answered it this way:  “Is it fair that we’re facing all these changes?”  He said, “Dude, let me rephrase that.  Medicare (and I think we can actually put all pairs in this) doesn’t pay the income aspirations of union people for doing things exactly the same way you’ve been doing them for 25 years.  Change the way you do the things you do like every other industry’s had to do over the last 25 years.”

So, dudes, it’s our time.


Dr. Eastman:

For those of us that know Chris, Chris was a cop before he became an administrator, but he’s never lost that. In addition to being a CEO, Chris leads the San Diego Search Rescue and is an EMT, David.  So, I think Chris, you do qualify to sit up here with a bunch of operating surgeons.  Dr. Talamini.


Dr. Talamini:

Hi.  My name is Mark Talamini, and it’s thrilling to have a room full of folks interested in this topic this morning.  San Diego has much to be proud of really.  We have David Hoyt from UCSD, Dr. Eastman, and really, they form the leadership of the American College of Surgeons from here in San Diego.  It’s great to welcome David back as really the product of UC San Diego when he spent many, many years working there, germinating some of the things I’ll tell you about very briefly.

So, I would like to take my moments to tell you how these four points have played out at UC San Diego.  It’s through the agency of a quality council that meets twice a month for two hours.  It’s run by Dr. Angela Sosha, who is our chief medical officer who’s here this morning.  This is a high level committee with chairs, the administration of the medical center, interested parties, and it does exactly what Dr. Hoyt pointed out in terms of these four areas.  It identifies what the priorities are going to be for the organization in terms of quality.  It decides what metrics we will use to measure that quality.  It comes up with tactics to drive change to improve the quality, and then, groups report back to that committee, finishing that circle.

So, I’ll give you just a few examples in surgery, and surgery, of course, is intimately involved in this.  First is through the agency of that committee. We did crew resource management training for all of our surgeons.  The deal was if you wanted to operate in our operating rooms, you did the training, including the check lists, time outs, debriefs at the end of the case.  So, we have a cycle of improving each case, and we continue to drive that now, even four years after that initiative.

A second exciting endeavor where we’ve seen change occur that’s specifically a surgical issue is central-line infection rates.  A few years ago, those were in 4 to 5 range.  I believe when most of us trained in surgery, we would have said that number can’t go to zero.  Sorry, can’t happen. Our team began thinking of ways that we can drive that number down.  It used to be 5 per 1000 patients at UC San Diego.  Our most recent quarter, the number was zero for the quarter.  Zero in central line infections, again, demonstrating that this process of coming up with strategies, coming back to the committee over and over again. Where are we?  Where are we making progress? What’s working?  What is not working?  These can result in great outcomes.

Third example is we are a NSQIP hospital.  We have been for the last five years, and that becomes a treasure trough of potent data because it’s risk-adjusted.  It’s down to the individual surgeon.  Again, we bring that data back to this quality committee on a quarterly basis, ask questions, and our most recent data for general surgery mortality, which we just got last night, shows that we’re in the 10% nationally for mortality in general surgery operations, again, demonstrating what the priority is, developing tactics can actually work.

Finally, what I want to say, as Dr. Hoyt showed you, we’ve invested a large amount in our training center in ACS-approved training center right across the way, and we have many objectives for having built this.  I believe it’s one of the finest such facilities in the world.  When put simply, 20 years ago when you finished training in surgery, you got a certificate that said you can do any operation for the rest of your life.  Well, we now know that makes no sense because surgery is change every five years.  We have surgeons in our faculty and some in the city doing things that are not done anywhere else in the country.

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