College of Surgeons San Diego Inspiring Quality Forum P5

Dr. Schumacher:

Hi.  I’m Mark Schumacher.  I’m a general surgeon and the physician director of the patient services at San Diego.  I want to expand on something that Dr. Kobelja touched on at the end of this talk.  That has to do with institutional culture.  Kaiser is a big support of NSQIP, but ultimately, the outcomes are dependent on the people that institute the processes that you’re trying to change.  That’s one of the realizations that we had a while back.

About a year and a half ago, we started a process of looking at our culture and seeing the opportunities to improve it.  We started out with an objective measurement.  We used the safety attitudes questionnaire that Peter Provonost and others have shown correlates well with clinical outcomes.  We found that we had opportunities for improvement in our culture.

As we began to analyze our culture, we realized that in the operating room and the pre-operative areas, we had high functioning individuals, but each individual had an expectation that they were infallible and the other people around them were infallible.  Another thing is inducing stress in others is something that would increase performance.

So, we took this on, starting out with group messaging.  We had off-sites and meetings where we presented to our folks, what would happen to our institution if this continues.  We also gave them the message that we want to invest in you.  We wanted to invest in a change.

We brought in an outside consultant and an educator to teach effective communication skills to people.  We taught our managers the concept of just culture.  Just culture is the concept of holding people accountable, but it’s also recognizing that we’re not going to be able to eliminate systems issues.  More importantly, we’re not going to be able to eliminate human errors by punishing people.  Instead, it’s more important to learn from adverse outcomes that it is to meet out punishment.

We invested in giving people in the front lines the support that they needed to identify the problems and making the changes to solve these problems themselves as opposed to a top-down management style.  We’ve done this through using unit-based teams and to patient-safety teams that are constituted of front-line people.

We’ve also done one-on-one work.  The leaders in the organization were encouraged to focus on problem children within their management structure and work with them one-on-one.  We’ve instituted scripted leadership rounding to promote safety and communication.  We’ve got a new on-boarding curriculum for new hires that stresses the importance of teamwork, and we’ve done consistent messaging.  You have to keep bringing this message back to your people over and over and over again in as many different forms in as many different ways possible.

So, in this last year and a half, I’ve seen some dramatic changes within the institution on my own executive rounds, and I’m looking forward to this fall when we’re going to have our next executive rounds of the safety attitude questionnaire that I’m convinced is going to show us objective measurements of change in our culture.


Dr. Eastment:

Thank you very much, Mark.  That’s a very different perspective, and hopefully, we’ll elicit some response to that particular approach.

Our next panelist, David Chang, is not a surgeon.  He’s not a physician.  He’s a PhD.  He might be the smartest person on the podium.  David came from Johns Hopkins, as did Mark Talamini.  Actually, we’ve rated Johns Hopkins, but David, I’ve had the opportunity to write a paper with David.  He’s a true academician in the realm of healthcare policy.  I think you’ll see his name more and more as he’s really producing the evidence we all talk about.

So, David?


David Chang:

Thank you, Dr. Eastman.  It’s a great honor to be here.  I guess I’m the only outsider in this panel.  I am a health services researcher by training with a background in health policy.  I am actually fortunate to be in departments of surgery all my professional life, first at Johns Hopkins and now at UCSD.

So, I come to this with an outsider perspective.  I’m fortunate to have mentors like Dr. Futchlock, Dr. Talamini, Dr. Eddie Quinwell who got me into this.  I have three points to make:  First is what does this mean to me as a policy person.  I think from a health policy perspective is that this is an attempt at more organization in healthcare, and this is what Dr. Hoyt talked about with the Institute of Medicine report.

The Institute of Medicine report had talked about this issue with the lack of scientific evidence in healthcare.  This is a problem that’s causing medical errors.  This is a problem that’s causing fragmentation like we talked about before, and I think NSQIP presents a unique, innovative effort at more organization in healthcare.

Before you really think about this, we actually don’t have a lot of organization in healthcare today with the notable exception in trauma as has been pointed out.  I think it’s not a surprise that we’re here today with surgeons like Dr. Hoyt and Dr. Eastman who started this in San Diego decades ago.  In fact, the trauma system innovations like the National Trauma Databank came under UCSD under Dr. Hoyt’s leadership.

So, when we talk about quality, what I see as a health policy person is more organized systems of health care, and I’m excited because I think it’s time that we push the system’s message out into the policy world.  I’m excited to hear the concept of professionalism that should be equal to accountability.  That’s an issue I think hasn’t really been addressed in healthcare.  I’m also excited of this move from eminence to evidence-based medicine.

Again, that’s why I’m in the audience.   I’m probably the most junior person on the audience, and I think this culture of evidence-base allow someone like me to be able to speak out.  This is something where I work with a lot of medical students and residents.  I really try to encourage them to speak out with evidence.  So, that’s what I see as a policy person.

What I think this represents to the people in the policy world is this message that we should be focusing on quality.  The problem with policy makers is they often focus on money, and that’s the only thing they understand.  If you think about the discussion on policy, the question is how to really spend money.  I think this is really inappropriate, at least when it comes to healthcare, because focusing on money is really misguided.  It won’t actually save money.  We would spend more money in the long run.

So, what we should do is focus on quality.  As the data has shown, focusing on quality actually reduces cost.  So, you might spend a little money up front, but we should see that as an investment, and ultimately, we will save money in the long run.

I think this is an important message to get out to the policy makers, and so, I’m glad that the American College of Surgeons has actually involved policy makers in this processes.  That’s what we’re trying to do in UCSD at the local level, engaging some of the policy makers here in California.

I think, as policy person, what’s important is what this represents to the larger society outside healthcare, and I think that might be the missing point in this whole debate.  WE might be preaching to the choir.  Everyone in this audience understands this quality message, but it occurred to me when I started working with medical students that medical students don’t understand NSQIP.  Most of the medical students who rotate to surgery have never heart of NSQIP.  They don’t know this concept of risk adjustment, and if students don’t understand this, I bet you 99% of the patients there don’t know about NSQIP.

I’m glad to hear the approach that the College is taking.  This housekeeping seal of approval.  This is what we really need to get out to the society that the objective work is to measure quality, and patients need to demand for this.  Again, this is a bigger problem than NSQIP.  The society, in general, does not understand quality, does not know that quality can be objectively measured.  This is actually a problem that the government outreach has put out a huge RFA to look at how to report quality in a way that the public understands.  So, this is something where I’m glad the College is actually taking the lead.

So, it’s surprising, in closing, that in the state of Facebook and Yelp, that most of us still pick our doctors based on an alphabetical list provided by our insurance companies with no quality data to guide us.  So, I think we’re very lucky to have leaders like Dr. Eastman, Dr. Hoyt, Dr. Martelini and others on the panel.

We could actually get this started, but I don’t think we can do the work ourselves.  We really need to get the public involved, and I think I really like the video at the end of Dr. Hoyt’s presentation.  That’s probably the funnest way to deliver this message of quality that I’ve heard of because when people think of quality, they should really try applaud.  That’s probably the coolest video I’ve ever seen about quality.

It actually reminded me of a video that one of the UCSD students made.  It’s a rap video in our medical school, about how they studied for the boards the library.  Maybe that’s the next step, get one of the medical students to make a rap video about quality.  Thank you.


Dr. Eastman:

Thank you, David.  Our last panelist, I’m particularly pleased to introduce, but I’m right on time.  I really think that Jim LaBelle at Scripps has recognized two things.  First, he talked about horizontal integration.  He talked about coal management that we’re never going to see going forward if we’re not managed by a very collaborative relationship between physicians and hospitals.

We read the history, David, has come and gone.  There have been chasms in the past.  Jim LaBelle was really only one of the two new appointments in the whole structure that Chris created, and it is the vice-president of medical management, co-management, and quality.  So, I thought that Jim could tell us what the heck that means.


Jim LaBelle:

Thank you, Brent.  My name is Jim LaBelle.  I’m an emergency physician who sometimes pretended to be a surgeon, but I recently took a role at Scripps which the title is corporate vice-president of quality, medical management, and physician co-management.  I briefly wanted to touch on why those are connected because I think that we’ve gone from a world in which quality’s a department in a hospital, and it really has become an attribute to an organization. Intimate to that is how we connect quality to the bedside, and it really is about physician leadership and engagement around that.

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