College of Surgeons San Diego Inspiring Quality Forum P4

So, how do we continually train our workforce in these new ways?  We can ill-afford to put any trained surgeons in the shelf for lack of training.  So, having these sorts of centers where surgeons can come to learn procedures, hone their skills, is another part of our quality improvement.

So, I thank you very much for the opportunity to share how this is working out at UC San Diego, which gave the world, in many ways, Dr. David Hoyt.  Thank you.


Dr. Eastman:

If you’re wondering why everybody is so on-time, would you show your red cards? When we talked about this panel and there could be many of you who are sitting here who should be on this panel, we really felt we should be reminiscing San Diego with all our history with the United States Navy.  To not have a representative from the military and specifically from the Navy.  Does anybody know what the largest hospital in San Diego is?  It was when it was here.  The Hospital Ship Mercy [41:47].  So, that is something that we’re reminded of.

In times of war, we have the privilege of helping train some of the people to take care of the wounded warriors.  In times of war, we have the chance to go and participate in military operations on a medical basis.  My trip to Blanchfield, Germany told me that there is no better trauma system.  David talked about the trauma system in San Diego.  There is no better trauma system, in my estimation, in the world than the Joint Forces Trauma System taking care of the wounded warriors today.  So, Mark, it’s a really a pleasure to have you on the panel.


Dr. Mark Kobelja:

Well, thank you very much.  I’m just glad to be here. I’m surrounded by so many distinguished speakers.  I feel I need to say very little and turn the conversation over.  I’m the token anesthesiologist, but that’s an important point.  Currently, my position at the hospital is as a commander.  So, I’m the chief operating officer for the hospital, and anesthesiologist is the add-on.

It’s important to note that the American College of Surgeons recognizes and has for a very long time that it’s not just about the surgeons, but it’s about every single person responsible for the care of the patient in surgical environment.  All the professions have come together, and the fact that we have several professions represented in the panel and in the audience speaks to that.  I think we had a nice discussion about that in the opening remarks.

NSQIP is an important first step.  It’s outcomes-based.  It’s a way of looking at patient care that focuses not on indicators or good practice or best practice, but how did the patient actually do? That is powerful information to have, and it’s not just the surgeons that care deeply about that.  It’s everybody involved in the care of the patient.  So, NSQIP is an incredible tool because it’s so fundamentally focused on the outcomes of the patient.

NMCSD has been involved in NSQIP since 2004.  In fact, we joined the VA in one of the early DOD pilots, and then the DOD took a great interest in NSQIP in working through the health affairs.  That’s the large organization that all of the funding flows through.  It has worked with the American College to figure out a way to get all the NTFs involved.  I think we have 19 participating institutions at this point.  This is not an easy feat because DOD hospitals, in particular, are held to some federal legislation requirements that really don’t allow us to share our data openly, our outcomes data, QA data openly.

The American College has done amazing work in working with us at the DOD level to figure out a way to separate out the data and to help us look at our patients doing a comparison to the national that meet the US Code requirements that we have to follow.  Why all this effort on NSQIP in particular?

The military is often the training platform for future surgeons and any anesthesiologist that go into the communities.  I’m sure many of you in your hospitals have many staff that come from the military.  So, we have the obligation to teach them that, but we also believe that NSQIP and other quality programs improve the care.  It does work as I think has been poignantly pointed out today.

The other challenge we have in military and Navy medicine, Balboa, in particular, is at the end of the day, the uniformed medical officers are on a surge platform.  We’re hired by the American people to go forward, to be operational, to be that extra judiciary medical force that joins our operational forces, surges forward for humanitarian relief, for disaster relief, whether it’s in the US or overseas.  So, having employees that are coming and going makes it more complicated to track quality.  This gets back to why NSQIP has proven to be so valuable for us.

Lastly, quality and the focus on outcomes and team-based approach is a little bit about culture, and I think that has been addressed a little bit about today.  My view is that the old saying that “culture eats strategy for lunch” is absolutely applicable here, and even know now, seven years later in the NSQIP battle, we still do this hand-to-hand combat with the culture of the individual practice, the arsenal approach to medicine.  It’s the kind of leadership coming from the American College.  It’s the kind of leadership coming from the senior leadership, in all aspects of medicine, that’s going to drive this debate to where it needs to go.

I’m very happy to participate in this, and I think you for the opportunity.


Dr. Eastman:

Thank you, Mark.  I began by asking, “What’s the largest hospital in San Diego?”  Chris Van Gorder commissioned a history of Scripps Health.  I know all about it because my wife was the author.  It was just completed.  The facts in there, there was a lot about the relationship with the Navy, but one of the facts is that at one point, Balboa Hospital was the largest hospital in the world.  Anybody want to guess how many best there were at the peak of Balboa?

Admiral?  Disqualified.  Conflict of interest.  By the way, welcome Admiral.  By the way, 10,000 beds.  After Pearl Harbor, it was moved to San Diego, and it was all history from there.

We’ll move on, given the timing here, to our next panelist who is a friend and was a colleague of mine for many years.  Ralph will introduce himself.  Ralph and I have one thing in common.  We both did our vascular at UCSF in San Francisco in the 1960s, and somebody one said if you remember San Francisco in the 60s, you weren’t there.  Ralph, I remember, and I won’t ask you to comment whether you remember or not.


Dr. Ralph Dilley:

Thank you very much Brent.  With my time, I’ll give you a few concrete examples of what a hospital can do with a NSQIP program.  About six years ago, we decided to try to incorporate the NSQIP program in Scripps Green Hospital, where I’m chief of surgery.  We were convinced that this would be an outcomes program far superior to the quality initiatives that hospitals were asked to evaluate.  Most of those initiatives were process-type problems, very few were outcome type problems.

We felt that the NSQIP program represented that best possible outcomes type approach.  So, we started NSQIP about six years ago, and our first report looked pretty good.  We weren’t liars in the post-operative complications, but we decided to look at one post-operative problem, look at it in great detail and see what we can do.

We choice urinary tract infections.  We found that our urinary tract infection rate post-operatively was 1.8%.  The national average was 1.1%.  We put together and looked at all the urinary tract infections at Scripps Green, and we didn’t find anything earth shaking.  As a result of the MIDI, we did an intensive education program about post-operative urinary tract infections, about the management of the catheter, and about when a catheter could be removed.

This was before NSQIP criteria picked up the urinary tract problem.  We’ve monitored our urinary tract infections over a period of two years, and over a period of two years, it fell from 1.7% to 0.6%, a remarkable reduction.  So, you could see from that one very simple analysis, the huge improvement in post-operative urinary tract infections, which saved a great deal of money and improved quality for those patients who didn’t develop the urinary tract infection.

Our second look was with DVT and PE.  We were concerned that the DVT PE incidence in our general population was a little high.  It was a little high. It was certainly not an outlier, but the ratio I believe was about 1.8 or almost 2.  We took the NSQIP criteria, and we looked at all our DVT PE problems, and we analyzed them before SQIP and after SQIP.  We were able to demonstrate a huge drop in the DVT and PE incidents after SQIP criteria was introduced.  So, that’s a second type of problem that we were able to manage.

Our third was a much more embarrassing problem.  One of the reports came, showed that the surgical site of infection of general surgery and vascular surgery was 7.8%, a true outlier.  The national average was 2.9%.  I was very embarrassed because of my own service, and we rapidly put together a team that looked at every surgical site infection that we had.  We were able to identify the problem.  We initiated an education, and we were able to demonstrate by the NSQIP criteria, a marked fall in surgical site infections over a period of about a year.  So, now we’re down to about 1.8%.

So, NSQIP for us has allowed us to decrease the number of urinary tract infections, decrease the number of pulmonary embolic disease and DVT, and an early recognition of the serious problem with surgical site infections.  It has allowed us to implement changes that would improve that and to monitor those changes on an ongoing basis.

I would just like to finish by one fact.  At the last NSQIP national meeting, Matt Hutter at the MGH and the group did an analysis of post-operative infections, and it’s an important thing to keep in mind.  If a hospital system can decrease the post-operative infections by one percent, just one percent, the savings is huge in terms of cost and huge in terms of patients care.  So, there’s no question that this kind of an outcomes-based program is vitally important to control cost and improve quality.


Dr. Eastman:

Thank you very much Ralph.  I think you would all agree that Ralph has evolved from an imminence-based to evidence-based.


Dr. Ralph Dilley:

No, I’m still very eminent.


Dr. Eastman:

Dr. Schumacher, we’re particularly happy to have you in San Diego, and California Kaiser is just a critical component that takes care of more patients on an outpatient basis, I believe, more than anybody else in San Diego.  So, you’re responsible for the quality of care of a lot of patients.  We are really delighted that you could join us and if you could tell us what you’re doing at Kaiser.

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