Ernest Amory Codman MD

Reframing the Morbidity and Mortality Conference: The Impact of a Just Culture

ABSTRACT

Morbidity and mortality (M&M) conferences are prevalent in all fields of medicine. Historically, they arose out a desire to improve medical care. Nevertheless, the goals of M&M conferences are often poorly defined, at odds with one another, and do not support a just culture. We differentiate among the various possible goals of an M&M and review the literature for strategies that have been shown to achieve these goals. Based on the literature, we outline an ideal M&M structure within the context of just culture: The process starts with robust adverse event and near miss reporting, followed by careful case selection, excluding cases solely attributable to individual error. Prior to the M&M, the case should be openly discussed with involved members and should be reviewed using a selected framework. The goal of the M&M should be selected and clearly defined, and the presentation format and rules of conduct should all conform to the selected presentation goal. The audience should ideally be multidisciplinary and multispecialty. The M&M should conclude with concrete tasks and assigned follow-up. The entire process should be conducted in a peer review protected format within an environment promoting psychological safety. We conclude with future directions for M&Ms.

Quality Measurement as a Path to High Quality Care Comment on "Quality and Performance Measurement in Primary Diabetes Care: A Qualitative Study in Urban China"

A rigorous evaluation of the implementation of a diabetes quality measure implementation program across community healthcare clinics in Shanghai, China, where both quality measurement and primary care delivery are relatively recent but centrally supported, identified important concerns about the meaningfulness, feasibility, and accuracy of quality measures that are relevant to all quality measurement programs. These include the importance of stakeholder involvement in measure development and implementation, the need to select measures that accurately and reliably reflect care quality, the link between incentives for improved performance and data manipulation, the necessity for scientific credibility and practical feasibility of the measure, and the assurance that measure performance can be impacted by those being evaluated. In addition to elaborating on these aspects of quality measurement, we also discuss the need for quality measures that are balanced across established domains of quality, are not burdensome to participants, and are transparent, parsimonious, nimble, and oriented around continuous evaluation and improvement.

[Comparative analysis of the accreditation of medical facilities in Canada, Chile, the Autonomous Community of Andalusia, Denmark, and MexicoAnálise comparativa da acreditação de estabelecimentos de saúde no Canadá, Chile, Comunidade Autônoma da Andaluzia, Dinamarca e México]

Objective

To compare and contrast the characteristics of the accreditation process for health care facilities in Canada, Chile, the Autonomous Community of Andalusia (Spain), Denmark, and Mexico, in order to identify shared characteristics, differences, and lessons learned that may be useful for other countries and regions.

Methods

An observational, analytical, retrospective study using open-access secondary sources on the accreditation and certification of health care facilities in 2019-2021 in these countries and regions. The general characteristics of the accreditation processes are described and comments are made on key aspects of the design of these programs. Additionally, analytical categories were created for degree of implementation and level of complexity, and the positive and negative results reported are summarized.

Results

The operational components of the accreditation processes are country-specific, although they share similarities. The Canadian program is the only one that involves some form of responsive evaluation. There is a wide range in the percentage of establishments accredited from country to country (from 1% in Mexico to 34.7% in Denmark). Notable lessons learned include the complexity of application in a mixed public-private system (Chile), the risk of excessive bureaucratization (Denmark), and the need for clear incentives (Mexico).

Conclusions

The accreditation programs operate in a unique way in each country and region, achieve varying degrees of implementation, and have an assortment of problems, from which lessons can be learned. Elements that hinder their implementation should be considered and adjustments made for the health systems of each country and region.

Value-based healthcare analysis of shoulder surgery for patients with symptomatic rotator cuff tears - Calculating the impact of arthroscopic cuff repair

BACKGROUND

Surgical repair of full-thickness rotator cuff tears in symptomatic patients is known to offer significant benefits. Despite this there remains a lack of universal appreciation that such surgery offers high clinical value, with some commissioners even limiting access to it. The value-based healthcare agenda provides a means to design, deliver and measure the impact of healthcare to a defined segment of patients. The aim of this study was to measure the value of surgically repairing primary symptomatic full-thickness rotator cuff tears when outcomes and costs were assessed over an entire care pathway.

METHODS

A prospective study of patients undergoing rotator cuff tears repair was undertaken. Patients were managed using a standardised integrated care pathway. Subsequent outcomes and costs were measured over the whole care pathway. Outcomes were assessed from both traditional and patient centric re-formatted prisms.

RESULTS

Significant improvement in clinical outcomes where recognised when assessed from either the traditional or re-formatted prisms. Economic review of this approach revealed the pathway generated a sustainable and notable positive margin.

DISCUSSION

This study evidences how a well-designed value-based healthcare shoulder approach can be delivered and measured. It demonstrates rotator cuff surgery to be a high value treatment for patients with symptomatic rotator cuff tears.

The History of Quality: From an Eye for an Eye, Through Love, and Towards a Multidimensional Concept for Patients, Kin, and Professionals

In ancient civilizations, poor quality was dealt with according to the principle of "an eye for an eye." In the modern era we have learned from industry what quality really is. Quality includes standards, protocols, system thinking, and an understanding of variation to ensure good outcomes. In the post-COVID era, quality is not all about predefined specifications but rather about relationships and even love. Quality can now be defined as multidimensional, including person-centered care for patients, kin, and providers. Care should be safe, efficient, effective, timely, equitable, and eco-friendly. High quality is only possible if we include core values of dignity and respect, holistic care, partnership, and kindness with compassion in our daily practice for every stakeholder at every managerial and policy level. PATIENT SUMMARY: Quality of care is a multidimensional concept in which person-centered care is central. The care a patient receives should be safe, efficient, effective, timely, equitable, and eco-friendly. Attention should be given to dignity, respect, kindness, and compassion. There should be a holistic approach that includes partnership with all stakeholders. The only acceptable level of quality a professional should provide is the level they would accept if their loved one were to be the next patient.

Looking to Improve Your Practice? Consider the Science of Quality Improvement to Get Started

Quality improvement in health care is the responsibility of everyone (eg, patients, families, health providers, and administrative staff) to work toward delivering high-quality patient care, advancing professional knowledge and skills, and creating effective and efficient processes of care. Those involved in athletic health care, similar to other health care professionals, should strive to create patient care experiences that are safe, timely, effective, efficient, equitable, and patient centered. Exploring the differences between quality improvement and research will help define the focus of improvement sciences on the health of systems, which is to identify quality gaps and evaluate processes of care, as opposed to filling knowledge gaps. Furthermore, considering the principles of quality improvement will set the foundation for quality initiatives in health care to focus on patients, value teams, emphasize systems and processes of care, appreciate variability, and require data. With a greater understanding of the principles of the quality improvement sciences, athletic trainers will be better positioned to create a culture of quality improvement and to take the initiative in leading improvement efforts so that local systems support the delivery of high-quality patient care.

Volumising value: value-based healthcare and its coming of age

Value-based healthcare holds great potential to transform healthcare globally. This commentary reviews the historical milestones in its evolution and raises critical questions regarding how it should proceed.

National Quality Forum Guidelines for Evaluating the Scientific Acceptability of Risk-adjusted Clinical Outcome Measures: A Report From the National Quality Forum Scientific Methods Panel

: Quality measurement is at the heart of efforts to achieve high-quality surgical and medical care at a lower cost. Without accurate quality measures, it is not possible to appropriately align incentives with quality. The aim of these National Quality Forum (NQF) guidelines is to provide measure developers and other stakeholders with guidance on the standards used by the NQF to evaluate the scientific acceptability of performance measures. Using a methodologically rigorous and transparent process for evaluating health care quality measures is the best insurance that alternative payment plans will truly reward and promote higher quality care. Performance measures need to be credible in order for physicians and hospitals to willingly partner with payers in efforts to improve population outcomes. Our goal in creating this position paper is to promote the transparency of NQF evaluations, improve the quality of performance measurements, and engage surgeons and all other stakeholders to work together to advance the science of performance measurement.

Quality improvement model (IHI) as a strategy to implement a sepsis protocol in a public hospital in Brazil

A major challenge for hospitals in low-income and middle-income countries is to improve management of patients diagnosed with sepsis. The objective of the present study was to evaluate the Institute for Healthcare Improvement (IHI) Model as a strategy to implement a managed sepsis protocol aimed at reducing sepsis mortality. We performed a longitudinal, prospective, non-randomised study using PDSA cycles for translating and implementing improvement actions and tools. Baseline case mortality/case fatality data were collected, and compliance rates were evaluated according to the Surviving Sepsis Campaign guidelines (3-hour care-bundle). Sepsis multidisciplinary work teams were designated and were responsible to develop Driver Diagrams and implement process changes in the intensive care unit, wards and emergency department. Satisfaction levels of healthcare professionals were assessed (balance variables). The study was carried out in a public quaternary hospital, in São Paulo city, Brazil (Hospital Municipal da Vila Santa Catarina). The number of patients with sepsis studied was 416 who were followed over a 15-month period. The data analyses were carried out by statistical process control. Case fatality rates were kept below a prespecified target of 25% (15.9%) during the period. Satisfaction level of the participating staff was high (95.2%) and 71% of participants reported no work overload. The IHI model was found to be a feasible and useful strategy for implementing a sepsis management clinical protocol.

Quality improvement in pediatric urology-a historical perspective on street pumps, puerperal fever, surgical infection, and contemporary methodology

Quality improvement and patient safety (QIPS) can trace its origin back to the court of Hammurabi (circa 1700BC). However, it did not begin its evolution into its present methodology until the mid-19th century. It was through the application of quantitative parameters around the time of World War I that the field of QIPS has matured and gained a significant presence in the practice of medicine. Herein, the authors present a historical overview of this increasingly important field and correlate the current pediatric urology literature that has arisen from it. Because QIPS research is likely to contribute to efficient, streamlined health care through rapid changes to routine clinical practices, it would behoove pediatric urologists to familiarize themselves with its history and fundamental concepts.

Implementation of outcomes-driven and value-based mental health care in the UK

Health-care companies around the world face an unprecedented challenge of rising health-care costs, increasing life expectancy and escalating demand. Although national health-care budgets have increased (as a percentage of gross domestic product) health care continues to impart significant upward pressure on national expenditure, particularly in the UK ( Licchetta and Stelmach, 2016 ). Additionally a substantial funding gap will continue to grow ( Gainsbury, 2016 ). In response to this challenge a 'value' based strategy has gained momentum over the last two decades. Several pioneers of this approach (Sir Muir Gray at Oxford University, Professor Michael Porter at Harvard University and Professor Elizabeth Teisberg at Dell Medical School) emphasize the importance of organizations focusing on 'value'. Porter and Teisberg (2006) highlight the 'value equation' as obtaining the very best patient outcomes for each unit of currency spent. Gray expands on this model, describing three types of value: allocative, technical and personal ( Gray, 2011 ). Although some global health-care organizations have embraced the value-based agenda to transform acute care facilities, mental health providers have been slow to consider the benefits of this approach. This article gives a broad overview of implementing a value-based model in mental health care, the significant development resources needed, organizational issues, and finally concludes with the benefits and a vision of value-based mental health care for the future.

Strengthening Surgery Strengthens Health Systems: A New Paradigm and Potential Pathway for Horizontal Development in Low- and Middle-Income Countries

Global health is transitioning toward a focus on building strong and sustainable health systems in developing countries; however, resources, funding, and agendas continue to concentrate on "vertical" (disease-based) improvements in care. Surgical care in low- and middle-income countries (LMICs) requires the development of health systems infrastructure and can be considered an indicator of overall system readiness. Improving surgical care provides a scalable gateway to strengthen health systems in multiple domains. In this position paper by the Society of University Surgeons' Committee on Global Academic Surgery, we propose that health systems development appropriately falls within the purview of the academic surgeon. Partnerships between academic surgical institutions and societies from high-income and resource-constrained settings are needed to strengthen advocacy and funding efforts and support development of training and research in LMICs.

Emerging Role of Drills and Simulations in Patient Safety

Ensuring patient safety and optimizing outcomes in obstetrics and gynecology through improving technical skills, enhancing team performance, and decreasing medical errors has resulted in significant interest in incorporating drills and simulation into medical training, continuing education, and multidisciplinary team practice. Drills and simulations are ideal because of their wide range of application with various learners and settings. They provide a safe space to learn and maintain technical skills and to improve knowledge, confidence, communication, and teamwork behaviors, particularly for less common, high-stakes clinical scenarios.

Defining the Content for a Quality and Safety in Surgery Curriculum Using a Nominal Group Technique

OBJECTIVE

There is growing awareness of the need to provide surgical residents with training in quality and safety. Previous studies have revealed a need for a formal curriculum, but the content and structure of such a curriculum has not been defined. Our objective was to develop a surgery resident curriculum using a consensus, team-building approach.

DESIGN

This study consisted of moderated, structured focus groups using a nominal group technique to guide discussion. Participants generated rank lists of topics to be included and answered questions regarding structure and design of teaching and assessment modalities.

SETTING

Two separate focus groups among 9 surgical residents and 10 faculty experts in quality and safety were held in conjunction with the American College of Surgeons Quality and Safety Conference in July 2017. A total of 16 institutions were represented.

RESULTS

A total of 35 topics were initially proposed by the resident group and a total of 41 topics were proposed by the expert group. After discussion, each group reached consensus on a final list of 9 topics. Most topics in the final lists fell into the broad areas of improvement science and nontechnical skills. Residents indicated that most topics were, on average, poorly covered by their current training program, however, a wide range was noted within each topic. Faculty indicated a preference for didactic instructional methods and assessment using multiple-choice questions.

CONCLUSIONS

Quality and safety are integral components of surgical training. Learners and experts agreed that topics within the domains of improvement science and nontechnical skills should be included in a formal curriculum. Learners reported wide variation on how well these topics are currently included in graduate medical education training programs.

Quality metrics in coronary artery bypass grafting

Studies on the association between care quality, case volume, and outcomes in coronary artery bypass grafting (CABG) have concluded that consistent adherence to quality measures improves mortality rates and outcomes. However, the quality metrics are not well-defined, and their significance to surgeons and healthcare providers remains uncertain. We review the concept of "quality and quality metrics" and discuss their importance in the context of CABG.

Uncovering Cultural Barriers to Quality Improvement Learning in a Trauma Program: An Ethnographic Study

OBJECTIVE

Quality improvement (QI) training is an essential component of postgraduate surgical education and can occur through formal and informal education programs. Informal QI education requires that faculty take advantage of learning opportunities in the hospital setting. Trauma rotations appear ideal opportunities for informal QI learning given that performance improvement is a mandatory component of care at verified trauma centers. It is unclear, however, whether QI initiatives within trauma programs are well integrated into trainee education. This study explored the QI learning environment in a level 1 academic trauma center.

STUDY DESIGN

An ethnographic study using observation and interviews methods. The theoretical lens of hidden curriculum was used to interpret the data and generate hypotheses around faculty and trainee experiences.

SETTING

University of Toronto and Sunnybrook Health Sciences Center.

PARTICIPANTS

Twenty-seven observations involving more than 50 faculty and trainees; seventeen interviews with faculty and surgical trainees.

RESULTS

All faculty and trainees endorsed QI and informal QI learning. Discrepant experiences were found regarding opportunities to learn and do QI in the clinical setting. Faculty viewed themselves as perpetually doing and teaching QI while trainees perceived little to no QI learning. Trainees identified Morbidity and Mortality rounds as the main opportunity for QI learning; however, traditional teaching style through "pimping" and a largely clinical focus acted as barriers to QI education. Furthermore, trainees chiefly viewed QI as service to the institution, rather than as a form of learning, which contributed to their disinterest in taking up informal QI lessons.

CONCLUSION

Informal QI education is highly valued and desired in academic trauma centers but enduring teaching methods, inconsistencies in the cultural learning environment and a hidden curriculum devaluing QI learning are persistent barriers to change.

Systematic review of hospital-wide complication registries

Background

An institutional registry covering all surgical specialties could be an implementation tool in quality benchmarking between hospitals and aid determination of their cost‐effectiveness. The objective of this systematic literature review was to evaluate original articles on existing prospective surgical registries that can be used by single institutions across surgical specialties.

Method

A systematic review of the literature using PRISMA guidelines was conducted for articles focusing on hospital‐wide surgical registries. Single‐specialty retrospective registries, non‐defined outcome measures or system protocols, and studies not in English were excluded.

Results

Five articles were included for analysis. Evaluation of the articles revealed wide methodological heterogeneity in the classification and categorization of complications and data collection methods.

Conclusion

Ideal surgical quality monitoring systems should be real‐time, contain patient‐related risk factors, and encompass all surgical specialties. At present, such institutional registries are rarely reported and no consensus exists on their standard definitions and methodology.

Performance Indicators in Spine Surgery

STUDY DESIGN

Systematic review.

OBJECTIVE

To elucidate how performance indicators are currently used in spine surgery.

SUMMARY OF BACKGROUND DATA

The Patient Protection and Affordable Care Act has given significant traction to the idea that healthcare must provide value to the patient through the introduction of hospital value-based purchasing. The key to implementing this new paradigm is to measure this value notably through performance indicators.

METHODS

MEDLINE, CINAHL Plus, EMBASE, and Google Scholar were searched for studies reporting the use of performance indicators specific to spine surgery. We followed the Prisma-P methodology for a systematic review for entries from January 1980 to July 2016. All full text articles were then reviewed to identify any measure of performance published within the article. This measure was then examined as per the three criteria of established standard, exclusion/risk adjustment, and benchmarking to determine if it constituted a performance indicator.

RESULTS

The initial search yielded 85 results among which two relevant studies were identified. The extended search gave a total of 865 citations across databases among which 15 new articles were identified. The grey literature search provided five additional reports which in turn led to six additional articles. A total of 27 full text articles and reports were retrieved and reviewed. We were unable to identify performance indicators. The articles presenting a measure of performance were organized based on how many criteria they lacked. We further examined the next steps to be taken to craft the first performance indicator in spine surgery.

CONCLUSION

The science of performance measurement applied to spine surgery is still in its infancy. Current outcome metrics used in clinical settings require refinement to become performance indicators. Current registry work is providing the necessary foundation, but requires benchmarking to truly measure performance.

LEVEL OF EVIDENCE

1.

Quality Improvement in Athletic Health Care

CONTEXT

  Quality improvement (QI) is a health care concept that ensures patients receive high-quality (safe, timely, effective, efficient, equitable, patient-centered) and affordable care. Despite its importance, the application of QI in athletic health care has been limited.

OBJECTIVES

  To describe the need for and define QI in health care, to describe how to measure quality in health care, and to present a QI case in athletic training.

DESCRIPTION

  As the athletic training profession continues to grow, a widespread engagement in QI efforts is necessary to establish the value of athletic training services for the patients that we serve. A review of the importance of QI in health care, historical perspectives of QI, tools to drive QI efforts, and examples of common QI initiatives is presented to assist clinicians in better understanding the value of QI for advancing athletic health care and the profession. Clinical and Research Advantages:  By engaging clinicians in strategies to measure outcomes and improve their patient care services, QI practice can help athletic trainers provide high-quality and affordable care to patients.

Cultural adaptation and the Clavien-Dindo surgical complications classification translated to Brazilian Portuguese

ABSTRACT Objective: to generate a translated and validated version of the Clavien-Dindo Classification of Surgical Complications (CDC) to Brazilian Portuguese (CDC-BR). Methods: the process of translation and adaptation followed the guideline of Beaton et al., 2000. We divided 76 participating surgeons, in different levels of experience, from the Department Surgery of the Hospital de Clínicas de Porto Alegre, into two groups: Group I applied the original version (CDC, n=36);r Group II used the modified version (CDC-BR, n=40). Each group classified 15 clinical cases of surgical complications. We compared performance between the groups (Mann-Whitney test) relating to the level of experience of the surgeon (Kruskal-Wallis test), considering p value <0.05 as significant. Results: the performance of the Group II (CDC-BR) was higher, with 85% accuracy, compared with 79% of Group I (CDC), p-value =0.012. The performance of the groups as for surgeons experience displayed p=0.171 for Group I, p=0.528 for Group II, and p=0.135 for overall performance. Conclusion: we produced a translated and validated version of the CDC for Brazilian Portuguese. The instrument will be a useful tool in the production of evidence on surgical outcomes.

Quality Measurement: A Primer for Hand Surgeons

As the government and payers place increasing emphasis on measuring and reporting quality and meeting-specific benchmarks, physicians and health care systems will continue to adapt to meet regulatory requirements. Hand surgeons' involvement in quality measure development will help ensure that our services are appropriately assessed. Moreover, by embracing a culture of quality assessment and improvement, we will improve patient care while demonstrating the importance of our services in a health care system that is transitioning from a fee-for-service model to a fee-for-value model. Understanding quality and the tools for its measurement, and the application of quality assessment and improvement methods can help hand surgeons continue to deliver high-quality care that aligns with national priorities.

Clinical audit: still an important tool for improving healthcare

The use of data to challenge and improve healthcare has a long and distinguished history but has often failed to bring about expected improvements. It has never become fully embedded in clinical practice, probably because data alone are insufficient to drive change. There is now a greater appreciation that changing and improving healthcare requires changing behaviours. Clinical audit remains one of the important tools that can be used to facilitate such change.

Measurement of quality to improve care in sleep medicine

ABSTRACT

The Board of Directors of the American Academy of Sleep Medicine (AASM) commissioned a Task Force to develop quality measures as part of its strategic plan to promote high quality patient-centered care. Among many potential dimensions of quality, the AASM requested Workgroups to develop outcome and process measures to aid in evaluating the quality of care of five common sleep disorders: restless legs syndrome, insomnia, narcolepsy, obstructive sleep apnea in adults, and obstructive sleep apnea in children. This paper describes the rationale, background, general methods development, and considerations in implementation for these sleep disorder quality measures. The Workgroup papers are published in this issue under the following titles: Quality Measures for the Care of Adult Patients with Restless Legs Syndrome, Quality Measures for the Care of Patients with Insomnia, Quality Measures for the Care of Patients with Narcolepsy, Quality Measures for the Care of Adult Patients with Obstructive Sleep Apnea, and Quality Measures for the Care of Pediatric Patients with Obstructive Sleep Apnea.

The price they paid

BACKGROUND

Several individuals integral to the development of evidence-based medicine endured hardship for their efforts and beliefs.

CASE PRESENTATION

We present the history of three individuals who were integral to the formation of evidence-based medicine. All three individuals suffered as a result of resistance to change from colleagues as well as from within the profession.

CONCLUSION

Individual and professional collegiality in the face of change should be maintained. The efforts of our predecessors are honored and provide us with inspiration.

Statistical methods to monitor risk factors in a clinical database: example of a national cardiac surgery registry

BACKGROUND

Comparison of outcomes requires adequate risk adjustment for differences in patient risk and the type of intervention performed. Both unintentional and intentional misclassification (also called gaming) of risk factors might lead to incorrect benchmark results. Therefore, misclassification of risk factors should be detected. We investigated the use of statistical process control techniques to monitor the frequency of risk factors in a clinical database.

METHODS AND RESULTS

A national population-based study was performed using simulation and statistical process control. All patients who underwent cardiac surgery between January 1, 2007, and December 31, 2009, in all 16 cardiothoracic surgery centers in the Netherlands were included. Data on 46 883 consecutive cardiac surgery interventions were extracted. The expected risk factor frequencies were based on 2007 and 2008 data. Monthly frequency rates of 18 risk factors in 2009 were monitored using a Shewhart control chart, exponentially weighted moving average chart, and cumulative sum chart. Upcoding (ie, gaming) in random patients was simulated and detected in 100% of the simulations. Subtle forms of gaming, involving specifically high-risk patients, were more difficult to identify (detection rate of 44%). However, the accompanying rise in mean logistic European system for cardiac operative risk evaluation (EuroSCORE) was detected in all simulations.

CONCLUSIONS

Statistical process control in the form of a Shewhart control chart, exponentially weighted moving average, and cumulative sum charts provide a means to monitor changes in risk factor frequencies in a clinical database. Surveillance of the overall expected risk in addition to the separate risk factors ensures a high sensitivity to detect gaming. The use of statistical process control for risk factor surveillance is recommended.

Value-based shoulder surgery: practicing outcomes-driven, cost-conscious care

BACKGROUND

Pathology of the shoulder contributes significantly to the increasing burden of musculoskeletal disease. Currently, there exists high variability in the nature and quality of shoulder care, and outcomes and cost reporting are not uniform. Value-based practice aims to simultaneously maximize outcomes and minimize costs for given disease processes.

METHODS

The current state of the shoulder care literature was examined with regards to cost and outcomes data, initiatives in streamlining care delivery, and evidence-based practice improvements. This was synthesized with value-based care theory to propose new avenues to improve shoulder care in the future.

CONCLUSION

The treatment of shoulder disorders is ideal for the value-based model but has been slow to adopt its principles thus far. We can begin to advance value-based practices through (1) the universal reporting of outcomes and costs, (2) integrating shoulder care across provider specialties, and (3) critically analyzing data to formulate best practices.

Quality in orthopaedic surgery--an international perspective: AOA critical issues

Quality is a hallmark of health care, although it is difficult to come to a consensus on who gets to define what "quality health care" is. Most health-care workers enter this field with the goal of improving the health of their patients (and the community), and while everyone tries to do the best job possible, we must continuously seek better methods and techniques for achieving better outcomes. The passion for continuous improvement is fundamental, but passion is not sufficient by itself. There is substantial opportunity to improve quality and reduce cost in health care. Multidisciplinary teams that include physicians, nurses, and other ancillary care providers have led to decreased waiting times to see specialists and have also led to better management of chronic disease. By including ancillary care, providers can increase cancer-screening rates and have the potential to decrease readmissions. Moreover, the addition of hospitalists and physician assistants can produce quality and efficiency outcomes that are commensurate with those enjoyed by traditional house staff. However, truly improving performance is difficult due to questions about how we define "quality," design care processes, measure inputs and outputs, develop multi-stakeholder collaborations, and develop incentive programs for delivering "good" care. There is a definite need for more thorough and robust studies of the impact of pay-for-performance programs, with the inclusion of ancillary care providers. Current research has not shown that there is not enough evidence to be able to determine what incentive structure might "work" in a particular health-care system. Payment systems will continue to evolve to incentivize greater collaboration among providers to yield higher-quality, lower-cost care. Future efforts will necessitate the need for strong physician leadership in helping to develop an optimal care team that is as patient-centered as possible. Technology adds dimensions of capability to making improvement real and systematic, as well as providing safer care with fewer errors and better adherence to proven best practices. The drive for quality with technology produces better clinical outcomes and maximizes efficiencies and financial metrics of organizational performance. Technology also adds capabilities for capturing key metrics and reporting them back to clinicians and others. Improved data transparency informs those who can actually do things differently to produce better results and outcomes. While health-care entities strive to focus on quality of care, measuring and reporting such care in a meaningful way are difficult. The best chance of improving overall care for patients is through the adoption of systems that improve coordination and continuity, not by health-care staff working harder. Only through collaboration and integration can health care incorporate a culture for improving quality and patient safety.

The American Burn Association/Shriners Hospitals for Children Burn Outcomes Program: a progress report at 15 years

The American Burn Association and the Shriners Hospitals for Children Outcomes Program has been in development for more than 15 years. Many of the tools and important findings are described in this special issue of The Journal of Trauma. This unique program in outcomes research introduces a model for outcome assessments from the patient-centered perspective with a cohort of 1,140 children with burn injury after hospitalization for up to 4 years. The findings represent a fundamental contribution to the field of burn care for monitoring outcomes from the perspective of the parent or child/adolescent. The Multi-Center Benchmarking Study of four burn centers serve as a model for collecting empiric scientific data on the variation and the expected trajectories of recovery in the most important domains of patient outcomes and can inform clinical decisions and the conduct of health service research. The dramatic progress in survival of children with severe burn injury and other advances in burn management can now move into a new phase of understanding the most cost-effective components of this care.

The evolving landscape of quality measurement for heart failure

Heart failure (HF) is a major cause of mortality and morbidity, representing a leading cause of death and hospitalization among U.S. Medicare beneficiaries. Advances in science have generated effective interventions to reduce adverse outcomes in HF, particularly in patients with reduced left ventricular ejection fraction. Unfortunately, effective therapies for heart failure are often not utilized in an effective, safe, timely, equitable, patient-centered, and efficient manner. Further, the risk of adverse outcomes for HF remains high. The last decades have witnessed the growth of efforts to measure and improve the care and outcomes of patients with HF. This paper will review the evolution of quality measurement for HF, including a brief history of quality measurement in medicine; the measures that have been employed to characterize quality in heart failure; how the measures are obtained; how measures are employed; and present and future challenges surrounding quality measurement in heart failure.

Staying alive: strategies for accountable health care

The Patient Protection and Affordable Care Act signed into law in March 2010, has led to sweeping changes to the US health care system. The ensuing pace of change in health care regulation is unparalleled and difficult for physicians to keep up with. Because of the extraordinary challenges that have arisen, the public policy committee of the Society for Surgery of the Alimentary tract conducted a symposium at their 52nd Annual Meeting in May 2011 to educate participants on the myriad of public policy changes occurring in order to best prepare them for their future. Expert speakers presented their views on policy changes affecting diverse areas including patient safety, patient experience, hospital and provider fiscal challenges, and the life of the practicing surgeon. In all areas, surgical leadership was felt to be critical to successfully navigate the new health care landscape as surgeons have a long history of providing safe, high quality, low cost care. The recognition of shared values among the diverse constituents affected by health care policy changes will best prepare surgeons to control their own destiny and successfully manage new challenges as they emerge.

Neurosurgical intensive care unit--essential for good outcomes in neurosurgery?

INTRODUCTION

Neurosurgical intensive care units were increasingly agglomerated in large centralized interdisciplinary intensive care units in the last two decades. In the majority, these centralized interdisciplinary intensive care units were directed and managed by intensivists coming from anaesthesiology. We sought to review the evidence supporting neurosurgical intensive care as a highly specialized discipline resulting in benefits for the treated patients.

CONCLUSIONS

In general, neurosurgical and neurocritical intensive care has been associated with improved outcomes and reduced mortality rates, reduced length of intensive care stay, improved resource utilisation, decreased in-hospital mortality, and fiscal benefits.