College of Surgeons San Diego Inspiring Quality Forum P6

Because we’re in a rapidly evolving environment in healthcare, it’s a little bit of a struggle to keep up with the various aspects of how we’re moving forward with quality and the deal with affordability issues as well.  I think it really comes down to how we build a system of the future, how we re-engineer care, and physician engagement is crucial to that.  In systems which drive measurements of outcomes rather than processes other than processes is important to the individual physician.

If I can speak to you with risk-adjusted data around mortality rates or particular complications, then we can have broader conversations around the entire system of care than a particular measure which looks at, “Did I provide DVT prophylaxis for the patient?”  I think that this is crucial because until we can recognize that our systems of clinical care evolved and were never engineered in the first place and have deep conversations laying out how we want patients to get cared for and how key performance indicators are that support that care process, we’re not going to get to those systems that reduce complications and prove the efficiency of care.

I think that in this world, we simply don’t have a choice to go about that.  The affordability issue in healthcare is almost to the point now where it precludes conversations about quality, and until we can connect those two tightly, we’re not going to be able to make that work, which comes back to what Scripps Health is doing to make this happen. I think that what’s happened at Scripps over the past 18 months is building a management infrastructure to support the physicians in change.

Chris spoke briefly about the horizontal management structure, which is really about doing things at the same place at the same way.  It’s not really about having the same labor standards or using the same supplies, it’s about building systems of care that apply the same things in the same way in the same place.

I’d like to give one example that’s related to my profession.  About a year and a half ago, the ERs of Scripps recognized that we weren’t performing to a level that we needed to perform, neither in turnaround times, access to our physicians in the emergency departments, or frankly our bypass times for the EMS system.  We had to have a hard conversation as to why that was, and we came to the realization, as a group of ER physicians, across the system, that it was really our leadership, or relative lack of leadership that resulted in this.

We were, in fact, using triage and the EMS system to modulate the number of patients that were coming into our emergency rooms for our convenience, not built around the patients.  What’s more is the processes that we had built in the ER were really a physician-centric.  We weren’t communicating well with the nurses, and we weren’t engineering processes the met the needs of the patients.

That was a struggle to recognize, and I think that was a prototype of the kinds of conversations that we had at every venue and it could only be had by physician leaders.  Surgeons play a particular leadership role in the hospital in that the most expensive care and the highest risk to the patient is around the surgical care in the patient.  There’s almost nothing in the hospital that isn’t touched by the surgeon.

Suffice to say, our conversations came around, and we realized that it was no longer an option to use triage as a way to hold patients in the waiting room.  We had to allow our patients to go in the back immediately and get care.  We eliminated largely the triage function in a lot of our ERs.  It was no longer an option for the ER physicians to go separately to the patient from the nurse and make the patient have conversations twice with the nurse and the physician around the same historical data.  We needed to go together as a team.

I think this teamwork and collaboration piece is going to be reflected and echoed throughout our culture, and it’s going to feel great when we recognize how difficult it is to work as a team when we’re used to autonomy and not collaboration.  I think that one of the core ideals around NSQIP, and the fact that we’re using risk-adjusted data that has been vetted by peers is that it rouses deep conversations that really requires collaboration between surgeons.


Dr. Eastman:

Thank you so much, Dr. LaBelle.  Well, thank you.  It’s a daunting task to say everything you have to say with the expert thing here in five minutes, but you did it.  We do have the remaining time to open it up for questions.  What we would like to do is have succinct questions and direct it to one panelist.  If the others have something to add, they can.  So, are there any questions?

Yes?  Would you identify yourself, what you do, and your question.



[1:11:22] I just really wanted to say thank you, but I really want to acknowledge Dr. Chang because what I think you’re actually saying is true, how to reach out into the community, and your advocates can be that bridge.  Reach out to your advocates, seek associations, and act as advocates.  Thank you.


Dr. Eastman:

Thank you.  One for Dr. Chang.  Zero for the rest of the panel.


Dr. Dan:

[1:12:26]  I don’t know who I should direct it to.  I’m going to throw it out.  How can we explain different outcomes and processes that are being used for quality improvement or quality measurement, either with the same system or among different hospitals and having different results while they are using exactly the same measures.  Let me say for the urinary tract infection for using the ventilator-related pneumonias.  Different places are actually using the same measures to prevent those but coming out with different results.


Dr. Eastman:

If anyone understands the question, I would like you to answer it.  Good question, Ahmad.


Dr. Talamini:

I think your question really revolves around the issue of risk-adjustment, and that’s where NSQIP has made a major contribution to this world of data collection and analysis.  The problem, of course, is that no risk-adjustment system is perfect, and I think we recognize that the NSQIP risk-adjustment system is also not perfect.  That doesn’t mean that we shouldn’t try and make it as good as we can, and I think the College is committed and already has modified the system as we go forward on the basis of researchers like Dr. Chang and others to continually improve it.

I think we just have to acknowledge that no risk-adjustment is going to be perfect enough to exactly compare one hospital’s result to another, but that doesn’t mean we shouldn’t do it.


Dr. Dilley:

I think it’s very important question, too, and I would just like to add to what Mark said.  When we looked at the urinary tract infections, not a single member of our group felt that was anything wrong with it.  We were doing everything right, but until you actually look at all of the information, case by case.  You look at how they were cared for.  You, then, bring up these very, very small variations between practitioners that ultimately cause an increase in urinary tract infections.

So, I would say that if each hospital using the same outcomes program like NSQIP, looked at their conditions in very great detail, we would have a lot of unanimity of opinion.


Chris Van Gorder:

I’d also like to speak of the risks.  We’ve grown up as silos, all of our hospitals working differently, picking different systems and using the data in different ways.  I think there’s great importance with using standardization in terms of the systems we use and the data we use.

We’ve just now migrated to a common lab information system.  Prior to that time with the electronic health record, we practically had two different lab results with different standards.  Going the same way with electronic health record, actually, we have the same risk.  So, we have to standardize the systems we use, then we’ll be talking the same language.


Dr. Eastman:

Thank you.  Yes, Ralph?



First of all, wonderful clarity on the presentation.  You’ve got all the pieces together.  Patient advocate here obviously addressed some of concerns.

I’m sorry.  I’m Ralph O’Campbell, retired general surgeon, former CMA president, if I may be allowed to say that.  So, I’ve been in medical politics for a long time, but that’s not what I’m addressing here.  I have a question for you Brent.  Is this going to become an annual event?  Then, the second question is, since this affects so much of our community, for instance, the Chamber has a health committee, wouldn’t it be appropriate to always invite non-physicians to events like this?  This cube is so easy to understand.  I understand it, and if they understood it, maybe they could help us.

Dr. LaBelle is probably, for all of these institutions, going to represent the type of individual that’s going to put this into effect.


Dr. Eastman:

Thank you, Ralph.  I’ll ask Dr. David Hoyt, too.  I think we would be happy in the San Diego chapter of the American College of Surgeons to make this an annual event if there was an interest, and perhaps, David Hoyt and Nancy can tell us if that’s in the works.  She talked about this being continued.

Secondly, I’ll let you know that we sent out 1,000 invitations to date.  We tried very hard so that we just didn’t have the people from just our quality committees and our surgeons, which is what we have.  We had really hoped to get, Ralph, the people you had talked about.  We didn’t accomplish that so maybe we ought do it again.

I will tell you, we also invited out surgical colleagues from Mexico because we have a chapter from Baja, California.  Some responded, they were not able to come.  Some are probably still waiting to try to get across the border, but they, too, would like to get more involved in this.

David, do you want to comment about making this an annual event?  What’s your plan?


Dr. Hoyt:

I had hoped that this would be important enough to the conversation across the systems of care across San Diego that you would want to do this on an annual basis.  I think that is a dream that we could see this occurring in every community, really to foster ultimately the communication.

David, perhaps you could tell the story of what the College did in the 1920s and 1930s that you shared with us this morning that’s pertinent to this concept.


Dr. Hoyt:

Yeah.  We think ideas are always new, but really, in the history, it turns out that based on our chapter of distribution of membership in the organization, that became the central form.  This is before the internet, video, before any of the modern technology.  Literally, the educational show was taking on the road community by community.

In addition to spending the day teaching each other how to do surgical procedures, they would convene in the afternoon and invite the public to actually come and listen to what was going on.  It actually became one of the most popular sessions in communities, oftentimes drawing 200 to 500 people from the community in a small community to come find out what’s going on in the community.

So, maybe we can go back there.

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