College of Surgeons San Diego Inspiring Quality Forum

Dr. Brent Eastman:

I’m going to begin by reading the mission statement of the American College of Surgeons.  Most of our organizations have mission statements.  We may or may not live by them.  I will tell you that I and my relationship with the College we do, and you can judge it today based on what you hear. The mission statement is brief, but it says, “The American College of Surgeons is dedicated to improving the care of the surgical patient and to safeguarding standards of care in an optimal and ethical practice environment.”

You judge today, from the community, from our hospitals, our surgeons whether you think we are living up to that.  In the discussion with panel and the Q & A, we hope we can flush that out, and where we are not meeting the mission statement. Part of this inspiring quality is really meant to get out there.

I’d also really like to thank particularly Chris van Gorder’s and Scripps’ help for being willing to co-sponsor this event with the American College of Surgeons and Dr. Martelini is the professional chair of the department of surgery at UCSD.  He and I have been the local contacts, but in fact, we have really just done what the people at the college tell us.  I’ve learned over the years, that’s the way to be successful at the American College of Surgeons.  Just listen to the staff, and in this case, not only the staff at the College and Dr. Hoyt leading that, but it also is Weber Shandwick, really the communications firm that the College is working with this together.

I’d really like to recognize Nancy Longley, Stacy Kramer, and Jackie Bosch.  Would you all stand up because you’ve all really done the work in putting this all together.  We are a part of what is a (I don’t know, David, we haven’t used this term, forgive me, but I think it’s) Occupy the United States, and we trying to, if you will, occupy communities to have sessions like this, to be evangelistic about it, spread the gospel about patient care.

We all recognize.  We read it in the paper.  We listen to it on the news.  We’ve got a broken health care system.  Costs are skyrocketing out of control.  We can’t afford what we have, and yet, we are, as health care providers, those of you in the community, need to know that we are committed to helping solve this problem.  You’ll hear today that probably based on some of the political impasse that goes on in Washington, and frankly I’m sacramental that that’s not where it’s going to happen.  It’s really going to happen here with us, those of us who are patient, who demand quality and cost-efficient care, those of us who are providers who have to meet that.

I think what we’ll talk about today can be summed up nicely with what you all know about.  It’s almost become a cliché, but I think it’s fundamentally true.  That is the value proposition.  That is value equals quality over cost, and I’d like to point out that quality is what the patient sees.  They see what the quality is, the outcome of their operation in the case of surgery.  They see their bill.  They see the cost.  They see bankruptcy if they can’t afford to pay it, but value is what we must achieve.  The good news is quality and cost are not mutually exclusive.  In fact, the proposition has been evidence-based proven that by improving quality, which is what today is about, we can decrease cost, decrease the variation in care, and really have a sustainable health care system for those who follow us either as patients or as providers.

It involves change, and that’s not easy.  There’s a number of aphorisms about change.  One of my favorites is that everybody’s in favor of progress as long as it doesn’t involve change.  A couple of years ago at the Pacific Coast Surgical, the presidential address had a very creative title, I thought, which was “Change is good.  You go first,” and I think we have a number of people doing that.  Well, perhaps the best aphorism, and I think our keynote speaker who I will now introduce, will touch on that is what Mark Twain said, which is “Do what is right.  You’ll please only some of the people, but you’ll astonish the rest.”

We really hope today that what we are doing, what you are doing in the College of Surgeons is going to astonish the American public that we are committed to a higher quality, more cost-efficient health care system.  One of our charge, Mark and I had, was to have a keynote speaker, and they said that what they did at Hopkins was they had a United States senator.  In Washington D.C., I think they had a United States senator, and in Chicago, I believe they had a United States senator.  So, we invited a United States senator.

I thought, for sure, I could get Senator Feinstein.  Her father, Leon Goldman, was one of my surgical professors.  She used to make rounds with me in San Francisco where I trained, and I thought it was a slam dunk is what I told the colleagues.  Dianne said she couldn’t come so we thought we’d go to the lieutenant governor.  Ben Theisen said he couldn’t come.  So, we said we’ll go to the secretary of Health and Human Services.  She said she’d come, but then she had to have surgery.  So, she couldn’t come.

So, I was at the College meeting, Board of Regions meeting, and prevailed upon David Hoyt.  I said, “David would you come?”  He’s been involved in those but was not going to come here.  “Would you please come and be our keynote speaker?” To tell you what kind of a friend David Hoyt is, he walked over to his secretary’s desk, and he said, “What am I doing on March 2^nd?”  She paled and became diaphoretic and trembled, and she opened this book which was booked.  He said, “Clear it.  I’m going to San Diego,” and I don’t think she’s ever forgiven me, Dave, but David Hoyt did agree to come.  In fact, we’re lucky, better given the message to Dr. Feinstein, lieutenant governor, the secretary.

I think nobody better than David Hoyt should be the keynote speaker.  David comes by with his interest in all of this honestly.  We were talking about it this morning:  His father was an orthopedic surgeon in Ohio, and actually wrote the original Orange Book that some of us have seen.  It was the original setting of standards for pre-hospital care for paramedics and pre-hospital providers.

David edited that book, and he went on to have a career.  He went to Amherst College where he graduated with honors in English, not Pre-Med but English.  David, I hope you’ll forgive me, but I always think one of David Hoyt’s really most distinctive honors is that he is the only person, never mind surgeon, I know, who went to Woodstock.  David may or may not wish to talk about Woodstock.

David went to medical school in Ohio in Case Western Reserve, but importantly for us, he came West and did his residency at UCSD and also did his residency in immunology at the Scripps Research Institute with Dr. Cochrane.  Is Dr. Cochrane here yet?  Good.

Charlie, would you stand up please?  Charlie Cochrane.  The reason I was able to get David Hoyt to come is that I said we would have a little dinner with Dr. Cochrane.  I just want everyone to know, in this room, that Charlie Cochrane is now retired.  He’s been one of the most prodigious scientist in the country.  His contribution is the development of [8:51 inaudible] colleagues such as David Hoyt and Ron Mayer, joined the jury and got his immunology training at Scripps Clinic at the TSRI.  Charlie, thank you for being here.  I think that’s why David was willing to come.

Dr. Hoyt has made incredible strides in his first 2 years, 2½ years as the new executive director of the American College of Surgeons.  I’ve known David for a long time.  I was on the circuit committee.  Dr. Greg asked me, “Finally, would you comment on Dr. Hoyt because I had a conflict, which should remain silent.” I never told David this.  So, I said, “Yes, as my father always said, there’s nothing wrong with nepotism as long as you keep it in the family.”

So, I just made one statement.  I said, “Dr. Hoyt will always say what he does and do what he says, and we can count on him.  He was a unanimous selection.”  So, it’s really my pleasure and honor to introduce our executive director of the American College of Surgeons, friend and colleague, Dr. David Hoyt.  David Pogue, I think you and I share, is a great philosopher.  Everyone knows about The Enemy is Us, but what you may not know is that Pogue also said, “We are surrounded by insurmountable opportunity.”  I think that’s what today is about.

Dr. Hoyt:

Well, good morning.  Thank you everybody for coming.  Brent, thank you very much for that introduction.  Thanks Chris and Mark for helping to co-moderate this.  You know, it’s really a pleasure for me to come back to San Diego and be a part of this, and I’m not running for the Senate although it sounds like you may be able to do that.

What I’m going to do is frame the discussion this morning and try to tell you why we’re having these kinds of forums across the country and why we’re trying to do as a professional organization.  We are the largest surgical organization in the world, and what our commitment to quality is on behalf of ultimately our patients.

Now, if you look at an organization like the College, we really have three areas of focus:  Quality, education of our physicians, and most recently, really the last 20 years, advocacy because the complexity of the health system we work in today.  If you’re really going to establish educational and quality standards on behalf of your patients, you also have to be effective at advocacy.  I want to show you, to a certain extent, how this pressure and how this opportunity for participating in the quality discussion also gives us an opportunity for advocacy.

Now, we are about to embark on our 100^th anniversary, and over the last hundred years, the College has been intimately involved in the development of quality programs.  It started back in 1917 when the first hospital standards were developed for what was to occur in a hospital.  This ultimately became known as The Joint Commission.  In the 1950s, the American College of Surgeons, it’s fascinating, but they finally joined with three other organizations to form The Joint Commission outside, and the reason was, for the previous 35 years, they had not been charging for certification, and it was becoming too much of their budget.  It’s amazing.

Commission on Cancer, The Committee on Trauma, most recently programs like NSQIP, which we’re going to talk about.  Those have been our tradition, and really at the front edge of what we’ve offered on behalf of our patients.  In that process, we have developed what we’re calling Four Guiding Principles or Pillars, and these are really the pillars of the continuous quality improvement cycle.  The first is to set standards that are focused on individual patients, backed by research when possible or circumstances when not.  The building out of the infrastructure for our program including the articulation of appropriate staffing levels, equipment check lists.  The identification of measuring outcomes through rigorous data that’s based on medical chart review, post-discharge tracking.  Then, finally, subjecting yourself to peer review external verification.  This is really our bond with the public to have a verification program that assures the public that what we say we’re doing, we’re doing.  The Trauma Center is a wonderful example.