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– written by Ari Vinograd
Original article: http://besttoothpaste.net
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.
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.
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.
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. 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.
San Diego is probably a community in the country where they used these principle in developing The Trauma Center 30 years ago. It has really been a model for how we look at this. The trauma system is truly an example of disease management, and these principles are embedded in this concept. I think you’re all familiar with the wondering impact this can have. That graph in the right lower part of the slide is the original graph that compared the no trauma system. Preventable mortality was reduced and has held at that threshold for the last 32 years. In a way, this is our good housekeeping seal of approval based on these quality pillars, and that’s going to be the core of the message this morning.
Now, there are two major pressures on all of us in medicine today, and the first is the quality movement. To a certain extent, this started with the Institute of Medicine report To Err is Human. It was championed through the subsequent report Crossing the Quality Chasm. I think that led to the proliferation of quality measurement efforts, programs, and a lot of confusion. Actually, in the last year, there has been consolidation and alignment, at least in the federal level, and the evidence for that is in this slide. The top there is the National Quality Strategy that comes out of Secretary Sevilla’s office. You see the emphasis is on improving care, better care, healthy people in communities. So, prevention efforts and making that portable.
When you look at the largest pair, CMS, they are reflecting exactly the same philosophy through the Triple Aim of Don Brewer. He’s no longer the administrator, but the impact that his philosophy had where CMS is headed is, again, to improve the experience of care, improve the health of populations, and reduce per capita cost. Finally, the same organization, The Institute of Medicine, that started the quality chasms, led to the original To Err is Human report, in the last two years, has defined the concept of a learning health care system as the ultimate goal with the concept and contextualization of evidence. Their goal is to have decision making by 2020, 90% of the time, reflect the best evidence.
That’s one huge change that we’re under. Now, who has a learning health care system today? I would argue that the American College of Surgeons is well on its way to being a prototype in medicine for that. We use best evidence to establish surgical care standards. We have then disciplined ourselves to measure outcomes through databases that are designed to assure performance of standards. When we reflect on that data and find deviations, we use that data to reconfigure clinical trials. The introduction of new technology is able to be done through this kind of process. That, again, redefines best evidence.
So, this concept of a continuous loop of continuous quality improvement is embedded here in the way we think and in our programs as well as in many of your hospitals. The other major pressure that we’re under is the finally one, and we’ve all seen these slides, 2020, $4.5 trillion, 19% of GDP. Look at it another way, we currently, with all of our taxation opportunities, generate at a federal level, generate 18% of the gross national product. We can consume with Medicare, social security, and interest on our debt, 16%. If you think about that, the real dilemma that we have is without raising our taxes or without changing the revenue structure that we currently have, we’re using most of our health care dollar or most of our federal dollar for healthcare delivery and other entitlements.
The problem is that, then, is making us make choices that we as physicians really need to appreciate if we’re going to participate in this. Now, Uwe Reinhardt who’s a somewhat controversial economist at Princeton puts it this way, that the net social value from a health system really equals the gross value of the actual health care that you give to patients minus the opportunity cost to society. A lot of what you’re seeing in Congress being frozen right now is how much we’re going to be putting in health care relative to research, relative to infrastructure to roads, and all the other things that the government does. I’m not sure we have an answer to that, but I think that’s fundamentally important for us to understand.
Our message is that in the American College of Surgeons, we’ve got something to bring to the table, and we’re going to show you an example of this. We’ve found a way to lower costs and increase quality to, Brent Eastman’s point, the value equation. It’s based on this program called NSQIP. Many of you in San Diego are participants of this, and I want to congratulate you on the forward thinking to subject yourself to measurement of surgical programs and use this as a tool to improve.
Now, the actual premise, if you’re not familiar, with NSQIP is based on this slide. We refer to this as a caterpillar diagram, and it’s simply shows the performance, in this case, of 450 hospitals against some outcome. This could be surgical infection. This could be DVT prophylaxis. What you see in this is right there on red, the hospitals that are against the standard are performing less than what you would expect. In green, on the left, are hospitals that are performing better.
When you share this kind of data with physicians, it’s hard wired into our psyche, if you will, to try to improve if you’re in that red zone. Now, you can say that, and we all know how we would react if our performance in our practice showed a higher-than-expected surgical infection rate. The data shows this actually works.
Here’s a very important study by Bruce Hall and Cliff Ko who’ve been fundamentally involved in the development of this program. They studied over 100 hospitals, looked at it over three years, and showed that by participating in this kind of effort, 82% reduction in complications, reduction in mortality. That worked out to about one complication per hospital per day for an average 400-bed hospital. When you couple that with the cost of a complication which is probably conservative at about $11,000, each hospital then is actually having a cost savings of $3-5 million dollars. You spread that across all the hospitals in the United States, and you’re talking about a significant contribution to this health care dilemma of billions of dollars in cost reduction.
Now, the other important aspect of this is this drives a conversation, and one of the things we’re hoping to do with these forums is bring you a little closer as a community in creating collaboratives such as we have in Tennessee or Michigan. These collaboratives, again, are based on the database, but what they do is they foster people coming together, sharing data with one another and then finding solutions and common problems to work together on overall to improve. Again, San Diego has been an incredible leader in this regard, and again, I’ll fall back to the trauma system.
In San Diego County, there has been a conversation for 30 years between the trauma centers and the community through the medical audit committee, which is really the prototype model for these collaboratives. I’m sure, with time, you will move to this in a broader fashion.
Well, the surgeon of the future and probably physicians in general are really going to be parts of teams. They’re going to be leading safe, high performance teams, increasing the integration of surgical and non-surgical skills. I had a chance to see the hole in the ground for your new cardiovascular center. It’s a wonderful example for this, and we’re increasingly all going to be parts of systems of care. We’re going to be a held to a basis of evidence-bases more than in the past, outcomes data, which will reporting. These are really are givens today. We’re not there yet, but I think it’s the direction I think that health care is going. So, we’ve really got to be prepared to participate, and again, NSQIP program I think is a wonderful example of that.
Now, I just want to end a little bit on another topic which is really quality in education. How do you know a surgeon is competent to do a new procedure? That’s a real challenge because in the past, we’ve followed the “See-one-do-one-to-each-one” model, and that’s not objective and precise enough particularly with the concepts that are being put forth with new technology.
So, we’ve extended this concept of inspiring quality in objectifying and verifying education through the concept of accredited education institutes, and these are designed to be throughout the country and be places where surgeons can learn new skills and have validated that their learning has been appropriate. There’s a wonderful example again in San Diego UCSD that Dr. Talamini and his colleagues have developed, The Center for the Future of Surgery. These are the kind of things, in addition to the quality programs that are hospital-bases, that really need to be a part of our health care though process going forward.
In another way, we’re redefining our concept of professionalism. Whereas 100 years ago, the use of autonomy, authority, and assertion with surgeons has really evolved into further collaboration, evidence-bases, measurement, transparency, and really, we’re redefining our profession on behalf of our patients as accountability. This gets back, then, to the coupling of this quality initiative to our advocacy efforts.
To that end, we’ve developed the inspiring quality campaign, higher standards and better outcomes. We’ve taken this to Capitol Hill as a kickoff in May. We’ve had desktop conversations with many legislators to get them to understand this, and it’s been very interesting to see the effect that this has had instead of just going in and taking about payment reform or medical liability reform. Leaders at the legislative level are listening. They are interested in what physicians have to say, particularly when you talk about things that ultimately affect patients.
We’ve started these quality forums as another way to engage, at a more local level, this conversation, and we would encourage you to continue this in the San Diego community as well. We’re spreading this across the country as you can see. We’ve developed a lot of tools and ways to help you and assist you both in your hospital and in your community, and these are all available to you. We can provide them through the web or just simply by asking.
Finally, I’d just like to thank Dr. Eastman for his contributions in San Diego, but also the fact that he is now the president-elect of the American College of Surgeons. It just shows you what outstanding leadership he’s not only provided in San Diego, but he’s now going to provide now literally to the world.
I want to end with a little summary video that puts it together for you and gives our core message. I also want to thank our colleagues form Weber Shandwick for helping us put these things together so we can just click on that.
Again, Brent. Thanks very much for the opportunity to be with you today.
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.
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.
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.
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 2nd?” 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.
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 100th 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.